CAM OVERVIEW

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A SCIENTIFIC LOOK AT ALTERNATIVE MEDICINE

Overview of Complementary and Alternative Medicine (CAM)

Thomas J. Wheeler, PhD

Associate Professor (retired), Department of Biochemistry and Molecular Biology,

University of Louisville School of Medicine, Louisville KY

thomas.wheeler@louisville.edu

Revised 2023

This material was originally developed as the first in a series of handouts for an elective course given to medical students at the University of Louisville. An updated version was published in 2013.

Copyright 2023. Permission to copy for non-profit uses is granted as long as proper citation of the source is given.

DISCLAIMER: The material presented here is not medical advice. It represents the author's summary of scientific evidence concerning various topics. For medical advice, see your physician.

 A pdf file of this article (60 pages) is available at this site: CAM OVERVIEW 

CONTENTS

General aspects

National Center for Complementary and Integrative Health and its predecessors

Some common themes in alternative medicine

Scientific critique

Adverse effects

Integrative medicine

Functional medicine

Regulatory agencies involved in health claims

Organizations and web sites promoting critical examination of alternative claims

Legal and ethical issues

Fraud and quackery

Antivaccination efforts

Antifluoridation efforts

Critical thinking in evaluation of medical claims: philosophical issues

Nature of science

Scientific activities and methods

Skepticism and open-mindedness

Reviews of complementary and alternative medicine for different conditions

Glossary of complementary and alternative medical claims and practices

References

 COMPLEMENTARY AND ALTERNATIVE MEDICINE: GENERAL ASPECTS

Definition and scope

The term “alternative medicine” is used to describe medical  approaches that are not generally accepted by the scientific medical establishment, and which often are not covered by health insurance. There is an implication that the methods are used instead of conventional care.

Jarvis (2022. The semantics of quackery. Quackwatch) wrote, " So-called 'alternative therapies' are defined by what they are not. They are not part of standard health care. They lack scientific evidence of safety and/or efficacy and often lack a scientifically plausible basis. Yet they are promoted for use instead of science-based care. The alternatives to proven safety and effectiveness are unproven, unsafe, and/or ineffective. Such are not true alternatives."

In contrast, "complementary medicine” suggests the use of non-established therapies  along with conventional medicine rather than instead of it. Other terms include “complementary and alternative medicine” (CAM), “integrative (or integrated) medicine” (combining complementary with conventional), and “functional medicine.” (See sections on integrative medicine and functional medicine below.)

Ernst et al. (1995. Br J Gen Pract. 45(398):506): “complementary medicine is diagnosis, treatment and/or prevention which complements mainstream medicine by contributing to a common whole, by satisfying a demand not met by orthodoxy or by diversifying the conceptual frameworks of medicine.”

Shahvisi (2019. J Bioeth Inq. 16(1):99-112) provided some distinctions between complementary medicine and alternative medicine: "Complementary medicine therefore comprises all therapies or heuristics which complement SM [scientific medicine] but do not attempt to replace it. These are therapies which may be related to one’s lifestyle or obtained through one’s social relations: a healthy diet, exercise, massage, relaxation techniques, group or individual counselling. In other words, complementary medicine tends to involve engagement with determinants of health problems, rather than health problems themselves. These interventions generally have an evidence base, even though their effects are often incremental and long-term...Complementary therapies do not generally require medical supervision or facilitation, yet their benefits may be straightforwardly rationalized in line with SM, albeit generally in indirect terms. AM [alternative medicine], on the other hand, departs dramatically from the paradigms of science. AM is used as a replacement for SM, in part or in whole; that is, it sets out to treat ailments that would generally be considered to be medical in nature."

Jarvis (op. cit.) wrote, "adding ineffective methods to proven ones does not increase effectiveness. It increases the cost and may make it difficult for patients to differentiate between the effects of standard and questionable treatments. Moreover, many practitioners who label themselves complementary don’t provide standard treatment or administer it poorly."

The National Center for Complementary and Integrative Health has classified CAM into five “domains”:

1. Alternative medical systems (e.g., homeopathy, naturopathy, traditional Chinese medicine, Ayurveda)

2. Mind-body medicine (e.g., meditation, prayer, hypnosis, music therapy, biofeedback)

3. Biologically based therapies (herbs, dietary supplements)

4. Manipulative and body-based systems (chiropractic, osteopathic manipulation, massage)

5. Energy therapies, divided into biofield therapies (e.g., qi gong, reiki, therapeutic touch) and bioelectromagnetic-based therapies (involving unconventional use of magnetic fields). Note that this is not a logical "domain," because it includes both real and pseudoscientific forms of energy.

This series of articles (see complete list at: https://sites.google.com/site/kycahf/articles) covers a broad range of topics, ranging from approaches that are being considered seriously within scientific medicine to approaches that are scientifically unlikely or discredited (and some that are fraudulent).

Eisenberg et al. (1993. N Engl J Med. 328(4):246-52) reported that one-third of Americans used unconventional therapy within the previous year. As with later surveys, this is an overestimate, because it includes activities, such as relaxation and massage, that are not really unconventional. Nevertheless, the report sparked considerable publicity for the field of alternative medicine.

More recent data come from the National Health Interview Survey in 2002, 2007, and 2012 (Clarke et al 2015. Natl Health Stat Report. (79):1-16). The percent of US adults using "any complementary approach in the past 12 months" was between 32%and 36% in all three surveys. The most common forms were nonvitamin, nonmineral dietary supplements (18-19%); deep-breathing exercises (11-13%); yoga, tai chi, and qi gong combined (6% increasing to 10%, mostly yoga); chiropractic or osteopathic manipulation (8-9%); and meditation (8-9%). Although they are given a great deal of publicity, more exotic methods such as acupuncture (1.1-1.5%), homeopathy (1.7-2.2%), naturopathy (0.2-0.4%), and energy medicine (0.5%) had relatively small usage.

The 2017 National Health Interview Survey focused on three therapies. For adults, use of yoga in the past year increased from 9.5% to 14.3% from 2012 to 2017; meditation, 4.1% to 14.2%; and chiropractic, 9.1% to 10.3% (Clarke et al. 2018. NCHS Data Brief. (325):1-8). For children aged 4-17 years, yoga increased from 3.1% to 8.4% and meditation from 0.6% to 5.4%; use of chiropractic was unchanged (3.5% and 3.4%, respectively) (Black et al. 2018. NCHS Data Brief. (324):1-8).

Using data from the 2012 National Health Interview Survey, Jou and Johnson (2016. JAMA Intern Med. 176(4):545-6) found that "42.3% of CAM users do not discuss CAM use with their primary care physicians. Contrary to earlier findings, our results attribute most nondisclosure to physicians not asking about CAM use or to concerns about physician knowledge regarding CAM rather than to physician discouragement or negativity about the use of CAM."

Scott et al. (2022. J Integr Complement Med. 28(8):641-50) analyzed National Ambulatory Medical Care Survey data from 2005 through 2015. About 4% of office visits "contained a report that complementary health approaches were ordered, supplied, administered, or continued. Among complementary health visits, 87% of patient charts mentioned nonvitamin nonmineral dietary supplements. The prevalence of complementary health visits significantly increased from 2% in 2005 to almost 8% in 2015." An accompanying paper (Stussman et al. 2022. J Integr Complement Med. 28(8):651-63) examined reasons physicians recommended common complementary approaches (herbs and supplements, chiropractic/osteopathic manipulation, acupuncture, and mind-body therapies). "For each of the four complementary health approaches, more than half of the physicians who made recommendations indicated that they were influenced by scientific evidence in peer-reviewed journals...More than 60% of all physicians recommended each of the four complementary health approaches because of patient requests." Lack of perceived benefit and lack of information sources were most frequent reasons for not recommending.

A survey "showed that approximately 45% of active duty military personnel reported using at least 1 CAM type in the previous 12 months. CAM use when not counting self-prayer was approximately 36%" (Jonas et al. 2014. Med Care. 52(12 Suppl 5):S9-12).

Why patients seek alternative practitioners

Ernst (2005. Pharmaceutical J. 275:55) has categorized the reasons for using alternative medicine as “push factors” (negative) and “pull factors” (positive). These include:

Push factors:

• “Dissatisfaction with aspects of conventional medicine”

• Anti-science or anti-establishment attitude, leading to rejection of conventional medicine

• Desperation

Pull factors:

• “Hope for increased well-being and other positive outcomes”

• “Philosophical congruence” with the ideas of alternative medicine

• “Personal control over treatment”

• “Good relationship with therapist”

• Accessibility

Other reasons:

• • • Pleasant falsehoods vs. disagreeable truth. Fear of medical diagnosis.

    • Staying healthy vs. crisis intervention

    • Medicine has been too successful: people expect that everything should be cured quickly

    • Lower costs

Bishop et al. (2008. Am J Public Health. 98(9):1700-5) pointed out that some people use CAM as "treats," "personal luxuries, not directed at an identified health need."

Ayers and Kronenfeld (2012. Health Serv Res. 47(5):2081-96) concluded "when conventional medical care is inaccessible due to the organizational nature and structure of the health care system, both provider-based and non-provider-based CAM therapies are more likely to be used in greater number."

Tangkiatkumjai et al. (2020. BMC Complement Med Ther. 20(1):363) reviewed factors involved in using complementary and alternative medicine in different populations worldwide. "The top three reasons for CAM use were: (1) having an expectation of benefits of CAM (84% of publications), (2) dissatisfaction with conventional medicine (37%) and (3) the perceived safety of CAM (37%). Internal health locus of control as an influencing factor was more likely to be reported in Western populations, whereas the social networks was a common factor amongst Asian populations (p < 0.05). Affordability, easy access to CAM and tradition were significant factors amongst African populations (p < 0.05). Negative attitudes towards CAM and satisfaction with conventional medicine (CM) were the main reasons for non-use (p < 0.05)."

"Overall, the typical CAM user tends to be female, middle aged, and college-educated, with lower perceived health and a higher level of spirituality (seeking answers and understanding to ultimate questions regarding life and its meaning and relationship with the sacred)" (Widder and Anderson 2015. Res Social Adm Pharm. 11(2):288-96). These authors also noted that "modern medicine is seen as cold, artificial, toxic, and disconnected in comparison to the more personable, natural, pure, and holistic approach of alternative medicine that empowers a patient to be a part of their own healing."

Shahvisi (2019. J Bioeth Inq. 16(1):99-112) noted that "Women dominate alternative medicine (AM), both as consumers and service providers." This dominance "can be contextualized within a broader trend of women’s greater interest in spirituality and the holistic milieu...The holistic approach typified by many AM modalities is theorized to be attractive to women because it is coherent with, and legitimizes, the relationality that women are socialized to embody in their care-giving but at the same time validates notions of self-care which subvert the stereotypical care role and recognize the importance of a woman 'thinking about her own well-being rather than that of her dependents'.”

Education

Complementary and alternative medicine is increasingly being taught in medical school courses and programs. Various unscientific approaches are presented (likely with little critical analysis), such as homeopathy, naturopathy, acupuncture, and anthroposophic medicine. Gorski (2017 Oct 11. Respectful Insolence blog) noted that "the Academic Consortium for Integrative Medicine and Health successfully lobbied the LCME [Liaison Committee on Medical Education] to include CAM in its list of topics addressed in the LCME Medical Education Database relative to accreditation standard ED-10. Unfortunately, how that is done in practice is often in the form of entirely credulous teaching of CAM."

There are many available courses in alternative methods, giving continuing education credit for health professionals. Ring and Newmark (2018. J Altern Complement Med. 24(8):748-51) wrote: "In response to the growing number of providers seeking a new practice model, individual clinicians, educational organizations, and businesses are increasingly providing trainings and certifications in areas such as functional medicine, antiaging medicine, regenerative medicine, and integrative medicine. These trainings are typically offered as brief in-person courses or online modules. Some are promoted as profitable, turn-key sources of revenue. While these proliferating continuing education and certification opportunities can provide expanded options for providers and patients, they often lack third-party verification of their standards through organizations that accredit credentialing bodies. They may enroll medical doctors from any medical specialty, and typically lack clinical oversight in the practical application of diagnostic testing and treatments to real patients. In this context of practice expansion for clinical, business, or mixed reasons, providers from disciplines across the board risk going beyond their primary training in unethical or dangerous ways."

Insurance

A survey of primary care services in New Hampshire (Whedon et al. 2017. J Altern Complement Med. 23(4):264-7) found that "Compared with primary care physicians, the likelihood of reimbursement for any service was 69% lower for acupuncturists, 71% lower for doctors of chiropractic medicine, and 62% lower for doctors of naturopathic medicine. For any E&M [evaluation and management] service, likelihood of reimbursement was 69% lower for acupuncturists, 78% lower for doctors of chiropractic medicine, and 60% lower for doctors of naturopathic medicine."

Hall (2022 Nov 15. Science-Based Medicine blog) noted that "According to Medicare.gov: 'Medicare Part B (Medical Insurance) covers manipulation of the spine by a chiropractor or other qualified provider to correct a subluxation (when the spinal joints fail to move properly, but the contact between the joints remains intact)'." However, "no evidence for the existence of chiropractic subluxations has ever been demonstrated, and that there is no supportive evidence for the association of the chiropractic subluxation with any disease process or of creating suboptimal health conditions requiring intervention." Also, "Medicare covers up to 12 acupuncture visits in 90 days for chronic low back pain, with 8 additional visits if the patient shows improvement. (It doesn’t cover acupuncture for any other condition.)"

The opioid crisis has led to increasing coverage of non-pharmacologic treatments for chronic pain (such as acupuncture) in some Medicaid programs and other insurance plans.

Bellamy (2017 Dec 7. Science-Based Medicine blog) reported that "The Veterans Health Administration (VHA) has announced...that acupuncture, reiki, and reflexology, among other 'complementary and integrative health [CIH] practices' will now be included in the standard veterans’ medical benefits package...In addition to the ethical issues posed by integration of pseudoscience into medical care, funding for veteran medical care is a zero-sum game. Congress allocates a finite amount of money to the VA, so monies absorbed by, say, therapeutic touch, do not get spent on, for example, cognitive behavioral therapy for PTSD."

The rules governing health savings accounts cover "payments for legal medical services rendered by physicians, surgeons, dentists, and other medical practitioners." Bellamy (2017 Mar 16. Science-Based Medicine blog) pointed out that "The phrase 'payments for legal medical services rendered by . . . other medical practitioners' in the IRS’s rules at least implies that naturopaths, homeopaths, acupuncturists and TCM [traditional Chinese medicine] practitioners are covered in states where they are regulated if they have the legal authority to diagnose and treat." Moreover, since no documentation is required and an audit is unlikely, it is possible for ineffective supplements and other unscientific services to receive coverage.

Journals and media

There has been an explosive increase in research publications concerning complementary and alternative medicine. Ernst (2015 July 30. Edzard Ernst blog) noted that many papers are published in Evidence Based Complementary and Alternative Medicine. This journal published 76 papers in 2010; three years later, the number had increased to 1327. In addition to specialized journals in complementary and alternative medicine, mainstream journals have increasingly carried papers on the subject. Journals such as BMJ and JAMA have been criticized for presenting such papers without sufficient scientific skepticism.

Of special concern is the growth of "predatory journals." "These journals pretend to uphold scientific standards but do not. Typically they offer authors rapid publication, in part because they do not take the time to do high-quality peer reviews" (Oreskes 2022. Scientific American. 326(6):59). Ernst (2023 Mar 23. Edzard Ernst blog) noted, "research papers on so-called alternative medicine (SCAM) are now mostly published in one of the many 3rd class SCAM journals that have recently sprung up. There are so many of them that they, of course, struggle to get enough articles to fill their pages. In turn, this means that they are far too keen to publish anything regardless of its quality or validity. As a consequence, the quality of these articles and their authors are often dismal."

The spread of inaccurate health information in the media has become a major issue. Platforms such as Facebook, Google and Twitter have struggled with how, and whether, to identify and remove misinformation. The Internet is a powerful medium for promoters of unconventional methods, dietary supplements, etc. Much of the available information is unreliable. The Federal Trade Commission (see below), along with the FDA and other government agencies, has been active in fighting misleading information available on web sites.

Writers on platforms such as Substack find that their income from subscribers increases as their views become more extreme, giving an incentive for the promotion of unscientific ideas.

Mishori (2018 Feb 22. HealthNewsReview) reported on a 2013 study of "health claims and recommendations made on 'The Dr. Oz Show' and 'The Doctors'...The recommendations made on these shows only occasionally follow evidence-based guidelines. Often, we couldn't find any literature citation (such as a medical study) to confirm the claims made on the show. The costs and harms of the suggested treatments were often overlooked. And, the hosts on the show frequently hawked products made by companies that advertise on the show."

Medical crowdfunding is now resulting in large amounts of money being raised for questionable approaches. Vox et al. (2018. JAMA. 320(16):1705-6) examined crowdfunding campaigns on three platforms for five types of treatments. "These results reveal that a wide scope of campaigns for unsupported, ineffective, or potentially dangerous treatments are moderately successful in obtaining funding. Assuming that the funds raised are spent to pay for these treatments, donors indirectly contributed millions of dollars to practitioners to deliver dubious, possibly unsafe care." In another study, by Snyder and Cohen (2019. Hastings Cent Rep. 49(6):32-38), "One search of GoFundMe campaigns identified 1,059 campaigns for unproven and potentially dangerous medical interventions." Murdoch et al. (2019. PLoS One. 14(4):e0215805) analyzed articles on crowdfunding in U.S. and Canadian newspapers. "Articles portrayed crowdfunding campaigns positively (43.75%) and neutrally (47.92%), but rarely negatively (4.76%)...Few (8.63%) articles mentioned ethical issues with the phenomenon of crowdfunding. Ailments most commonly precipitating the need for a campaign included cancer (49.11%) and rare disease (as stated by the article, 36.01%)...More than a fifth of the relevant articles made a statement suggesting that the treatment may be inefficacious, experimental or unapproved by regulatory bodies. The majority of these articles still noted where contributions could be made and hyperlinked to the online crowdfunding campaigns. Such reporting could be interpreted as promoting and raising money for unproven or even fraudulent therapies."

Other developments

The number of integrated health centers, in which both conventional and unconventional practitioners can be found, has increased greatly in recent years. A survey found that 15% of community hospitals included CAM, with the number doubling between 1998 and 2000. A 2004 survey found that 95% of academic health centers included CAM, with acupuncture and massage being the most commonly offered therapies. "Some hospitals have built luxurious, spa-like wellness centers to draw patients for spiritual healing, homeopathy, and more. And they’re promoting such treatments for a wide array of conditions, including depression, heart disease, cancer, and chronic pain. Duke even markets a pediatric program that suggests on its website that alternative medicine, including 'detoxification programs' and 'botanical medicines,' can help children with conditions ranging from autism to asthma to ADHD" (Ross et al. 2017 Mar 7. STAT). See other examples in "Integrative Medicine" below. Novella (2017 Mar 8. Science-Based Medicine blog) wrote, "Many (I would say most) of those who think they want alternative treatments don’t really want to buy magic beans. They are just being misled. They falsely think that a hospital would not be offering the treatment if it were not legitimate."

State legislatures are being asked to recognize alternative professions and methods. Licensure of specific types of practitioners, such as acupuncture and naturopathy, is discussed in the articles dealing with those methods. Bellamy (2013 Jun 27. Science-Based Medicine blog) has listed "Six reasons CAM practitioners should not be licensed":

"1. Practice acts grant CAM practitioners a broad scope of practice, including legalization of scientifically implausible and unproven (or disproven) diagnostic methods, diagnoses and treatments...

2. CAM practitioner education is inadequate preparation for the scope of practice permitted...

3. The fox is allowed to guard the henhouse (self-regulation)...

4. Mandatory public and private insurance coverage...

5. Licensing confers undeserved legitimacy causing public confusion...

6. Licensing decreases important health care consumer protections."

So-called "health freedom" laws make it easier for unconventional treatments to escape rigorous oversight. Bellamy (2017 Oct 12. Science-Based Medicine blog) described two types of "health freedom" law. One would "allow people with no health care education or training to sell bogus treatments to the public without fear of being prosecuted for the unlicensed practice of a health care profession as long as certain minimal requirements are made." The other would "permit a physician to practice in a manner that would normally fall below the standard of care without fear of prosecution from the state medical board if certain requirements are met...Provisions vary from state to state, but generally require that the diagnosis or treatment not pose an undue risk or actually cause harm." Such a law means that "Physicians are free to discard evidence-based medicine in favor of pseudoscience." "Health freedom" laws are being promoted by National Health Freedom Action and the National Health Freedom Coalition.

"Right-to-try laws are U.S. state laws and a federal law that were created with the intent of allowing terminally ill patients access to experimental therapies (drugs, biologics, devices) that have completed Phase I testing but have not been approved by the Food and Drug Administration (FDA). Prior to the passage of right to try laws, patients needed FDA approval to use experimental drugs. As of 2018, 41 U.S. states had passed right to try laws. The framers of these laws argue that this allows for individualized treatments that are not permitted under the FDA's current regulatory scheme. Critics see the laws as an attempt by libertarians to weaken the FDA. The value of these laws was questioned on multiple grounds, including the fact that pharmaceutical manufacturers would have no obligation to provide the therapies being sought. A federal right to try law was passed in May 2018" (Wikipedia 2023. Right-to-try law). Phase 1 is small-scale testing for safety, but under these laws the drugs would not have to be shown to be effective (Phases 2-4), or to undergo the larger safety testing in phases 2-4. Critics note that the laws present risks of adverse effects to patients and open the door to provision of unscientific treatments. Patients likely would have to pay for the treatments themselves. "Harriet Hall, MD expressed concerns that patients may not completely comprehend the risks involved in taking medications available under the right-to-try law, nor understand the low probability of success, especially patients who were not healthy enough to qualify to participate in clinical trials. She states these patients may have other medical conditions that could make them more vulnerable to complications from experimental treatments" (ibid.). Joffe and Lynch (2018. N Engl J Med. 378(8):695-7) also noted that "despite the claim that dying patients have nothing to lose, granting very sick patients early access to unapproved products may be more likely to harm patients than help them." Also, "expanding access outside trials may delay the generation of data needed to make evidence-based decisions about approval and use of new drugs."

"In May 2013, the WHO [World Health Organization] released its Traditional Medicine Strategy 2014-2023, which continued a questionable mission begun in previous strategies and declarations. In this document, the organization argues that what it refers to as traditional and complementary medicine or T&CM is 'an important and often underestimated part of health care'...The WHO wants the integration of these prescientific healing practices into national health systems as a way to contribute to universal health coverage” (Jarry 2023 Apr 23. McGill Office for Science and Society).

Hall (2018 Jan 16. Science-Based Medicine blog) noted that compounding pharmacies "are often used injudiciously by naturopaths, 'integrative medicine' doctors, 'functional medicine' doctors, and other providers who prescribe treatments that are not supported by credible evidence and that often involve risky IV administration."

THE NATIONAL CENTER FOR COMPLEMENTARY AND INTEGRATIVE HEALTH (NCCIH) AND ITS PREDECESSORS

In 1991, Congress established an Office of Alternative Medicine within the National Institutes of Health, with funding of several million dollars per year (which is very small compared to the total NIH budget). This provided great publicity for alternative practitioners, who claimed that this showed that their practices were moving into the mainstream. However, OAM was a result of political pressure, not the scientific judgement of NIH that such studies are warranted.

In 1998, the Office of Alternative Medicine was converted to the National Center for Complementary and Alternative Medicine (NCCAM), which allowed it to fund grants directly. Stephen Straus was director from 1999 to 2006. Ruth Kirschstein was Acting Director from 2006 to 2008, with Josephine Briggs becoming director in 2008. The budget rose to about $140 million by 2012 (with comparable levels of funding of alternative medicine from other branches of NIH).

Critics noted that in the first nine years of research supported by OAM and NCCAM, no therapy had been shown to be either effective or ineffective, and that some areas of research were implausible.

NCCAM established many research centers at various institutions around the country, as well as two international centers. Grants were also awarded to medical schools to develop instructional programs in CAM.

Gorski (2013 Aug 21. Respectful Insolence blog), in discussing an article by Josephine Briggs and Jack Killen of NCCAM (2013. JAMA. 310(7):691-2), wrote: "So it appears that NCCAM has found its niche, the one area where placebo effects confound SBM more than arguably any other area, chronic pain. It's a savvy move. In what area are there probably the most seemingly 'positive' acupuncture studies? Pain and especially chronic pain. The same is likely true for just about any CAM modality, be it 'energy medicine' such as reiki or therapeutic touch, 'mind-body' modalities, herbal medicine, or just about anything else CAM. It's the one and only area of medicine where it's really, really hard to differentiate true effects from placebo effects, other than perhaps psychiatry, particularly the treatment of depression....

"The other accomplishments touted by Briggs and Killen include a string of negative studies of various supplements, such as St. John's Wort for depression, glucosamine and chondroitin for osteoarthritis, silymarin for chronic liver disease, saw palmetto for prostatic hypertrophy, vitamin E and selenium to prevent prostate cancer, and gingko for early cognitive decline. Of course, doing studies on all of these supplements is nothing more than rebranding the old and respected branch of pharmacology known as pharmacognosy (natural products pharmacology) as somehow being 'alternative' or 'CAM.' It's not. Testing natural products and trying to isolate active ingredients in herbs, for instance, is pharmacognosy. There is no reason to categorize such studies as 'CAM.' They easily fall within the purview of science-based medicine. Another point: All of these studies were negative, likely because the preliminary data were so weak and the prior plausibility wasn't so hot either."

Briggs and Killen noted a shift in funding away from "areas that have less scientific promise or less amenability to scientific investigation." Gorski wrote: "Translation: Ignore all that quackery we used to study in the past, like homeopathy distance healing, reiki, and the like. We don't do that (much) anymore."

"The NCCAM was renamed the National Center for Complementary and Integrative Health (NCCIH) in December 2014...The 2014 name change to NCCIH has been described by critics as an attempt by the center to mitigate criticism by avoiding the term 'alternative' and distancing itself from having funded studies of questionable merit" (Wikipedia 2023. National Center for Complementary and Integrative Health).

Gorski (2016 Jan 7. Respectful Insolence blog) commented on a post by Josephine Briggs concerning "what she considers to be notable research from 2015" funded by NCCIH. "Presumably, Briggs picked the three best examples of good science she could find from the entire NCCIH portfolio of grants. If that’s the case, her list strikes me as pretty pathetic. It includes research that has little or nothing to do with CAM and everything to do with molecular biology, biotechnology, and synthetic biochemistry, research that oversells placebo effects, and a clinical trial that reinvents the wheel by testing yoga as yet another form of exercise to help people quit smoking. More than anything else, this thin research portfolio indicates that NCCIH has no real scientific rationale to continue to exist."

Ernst (2016 Dec 14. Edzard Ernst blog) wrote, "No other institution in the world had more funds for research into alternative medicine than the NCCIH, and it soon became the envy of alt med researchers globally. I have been invited by the NCCHI on several occasions and invariably was impressed by their apparent affluence. While we Europeans usually had to do our research on a shoe-string, our American colleagues seemed to be ‘rolling in it.' I was often far less impressed with the research they sponsored. Not only it was invariably eye-wateringly expensive, but also its quality seemed often dismal. Sometimes, I even got the impression that research was used as a means of mainstreaming quackery for the unsuspecting American - and consequently world-wide - public."

Novella (2018 Jan 17. Science-Based Medicine blog) wrote, "I would also add to the list of potential harm of pseudoscience in medicine, redirecting limited resources away from more promising treatments and research. The very existence of the NCCIH (National Center for Complementary and Integrative Health) proves this point. The reason for this center is to provide funding for research into treatments that could not justify funding with proper science. As a result billions of dollars have been arguably wasted without resulting in a single new treatment, or diminishing the use of CAM by proving it doesn’t work. This is a small percentage of the overall NIH budget, but still that is billions of dollars of wasted medical research."

Marcus (2020. J Clin Invest. 130(4):1549-51) wrote that "expenditure of approximately $2.2 billion by National Center for Complementary and Alternative Medicine (NCCAM)/NCCIH during fiscal years 1999–2017 for clinical trials produced no sound, consistent evidence for the efficacy of any alternative therapies. However, the grants lent academic credibility to integrative medicine."

In 2018 Helene Langevin replaced Josephine Briggs as director. Gorski (2021 Jun 28. Science-Based Medicine blog) wrote, "I gave Dr. Briggs some credit because I thought she was in an impossible situation. She was a real scientist trying to impose scientific rigor on an enterprise that was, by its very design, resistant to rigorous science. That she largely failed is probably not her fault; it was an impossible task. Dr. Langevin, on the other hand, has fit right into the culture at NCCIH, because she is a true believer. In brief, Langevin has been studying acupuncture ever since at least the 1990s, when she came up with the idea that somehow the needle interacting with the connective tissue is how acupuncture 'works'."

Gorski (ibid) compared the 2021-2025 NCCIH strategic plan to earlier 5-year plans. The five objectives were:

• "Objective 1: Advance Fundamental Science and Methods Development

• Objective 2: Advance Research on the Whole Person and on the Integration of Complementary and Conventional Care

• Objective 3: Foster Research on Health Promotion and Restoration, Resilience, Disease Prevention, and Symptom Management

• Objective 4: Enhance the Complementary and Integrative Health Research Workforce

• Objective 5: Provide Objective, Evidence-Based Information on Complementary and Integrative Health Interventions"

"Objectives 4 and 5 seem to appear in pretty much every NCCIH strategic plan in one form or another...That leaves Objective 2 doing the heavy lifting. This is where Dr. Langevin, true believer that she is in acupuncture, appears to be starting to make her mark on NCCIH. This objective has four strategies:

• Strategy 1: Promote basic and translational research to study how physiological systems interact with each other.

• Strategy 2: Conduct clinical and translational research on multicomponent interventions, and study the impact of these interventions on multiple physiological systems (e.g., nervous, gastrointestinal, and immune systems) and domains (e.g., biological, behavioral, social, environmental).

• Strategy 3: Foster multicomponent intervention research that focuses on improving health outcomes.

• Strategy 4: Conduct studies in real world settings, where interventions are routinely delivered, to test the integration of complementary approaches into health care.

"Let’s dispense with Strategy 4 first. It’s the same old, same old. Basically 'real world' settings is code for doing so-called 'pragmatic trials'...There is one requirement for a pragmatic trial. That requirement is that the novel modality being tested against standard-of-care must already have been demonstrated to work in randomized clinical trials...doing pragmatic studies on 'integrative interventions of the sort under consideration at NCCIH is putting the cart before the horse...

"I must admit that I laughed out loud when I read this part of Strategy 2: 'NCCIH hopes to expand research on integrated multicomponent therapies.' So NCCIH wants to study multi-modality, multistep treatments and look at multiple outcomes in a single trial! What could possibly go wrong? Here’s a hint: The more outcomes you look at in a single trial, the harder it is to power the trial to determine if a difference in one of these outcomes between control and intervention is significant, as the problem of multiple comparisons comes into play. As you might recall, the more comparisons you make, the greater the chance of one or more of them producing a 'statistically significant' difference by random chance alone...

"As for Strategy 3...This is another example of the 'rebranding' that 'integrative health' proponents are so slick at. At its core, Strategy 3 is little different from what scientists and physicians are already doing in terms of research into combining different modalities. The difference is, of course, that NCCIH will include prescientific systems of medicine, such as TCM and Ayurveda and quack modalities of naturopathy... chiropractic, and osteopathy, none of which are based on a scientific understanding of the human body and its biology, disease, and pathophysiology....

"The new plan is the same as old plans, and then some. It’s smarter in that it hides the quackery, something the last plan did, but in a cleverer way. Sadly, NCCIH appears to be back and poised to be as quacky as ever."

SOME COMMON THEMES IN COMPLEMENTARY AND ALTERNATIVE MEDICINE

Allopathy - this term ("opposite" plus "suffering") was invented by Hahnemann, the founder of homeopathy ("same" plus "suffering"). Allopathy was used to refer to early 18th century medical practice, in which "humors" and bodily conditions were "balanced" by harsh treatments (bloodletting, purging, toxic chemicals) thought to represent "opposites." It is currently used by some alternative practitioners as a derogatory term for conventional medicine, even though it is no longer a valid description of how medicine operates. "'Alternative' health-care providers label standard medicine 'allopathy' to make it appear that standard medicine is based upon an ideological principle rather than science. In reality, medicine is pragmatic in that it concerns itself with what works...The words allopathic, conventional, orthodox, and traditional should not be used to describe standard medicine because they suggest that standard practice is ideologically driven, authoritarian, rigid, or outdated rather than steadily improving due to scientific discovery" (Jarvis 2022. The semantics of quackery. Quackwatch).

Antagonism toward the pharmaceutical industry ("pharma") - the industry is seen as interested only in profits, and thus promoting expensive synthetic drugs and trying to suppress the use of "natural" alternative approaches.

Balance - treatments are claimed to restore “balance” to the body by adjusting “energy,” providing nutrients, removing subluxations, etc.

Criticism of conventional medicine - it is common for CAM advocates to cite statistics on deaths due to side effects of drugs or to medical errors. These criticisms fail to account for the fact that some risks are necessary in treating serious medical conditions (for which people usually do not choose CAM); some deaths are due to human error in application of appropriate methods; and that some patient deaths may have occurred anyway due to their serious conditions. In contrast, adverse effects of alternative treatments are generally not tracked, and their risks (even if minor) are not justified for treatments that confer no benefits.

It has been claimed that there are 250,000 to 400,000 deaths per year due to medical errors. Gorski (2016 May 9, 2019 Feb 4, and 2020 Feb 3. Science-Based Medicine blog; 2021 Aug 13. Respectful Insolence blog) refuted these figures. In the 2019 article he noted a study by Sunshine et al. (2019. JAMA Netw Open. 2(1):e187041) that gave a value of about 5000 deaths per year with adverse effects of medical treatment (AEMT) as the underlying cause. Gorski noted that "the vast majority of AEMTs that occur in patients who die aren’t the primary cause of death...only a relatively small fraction of AEMTs are due to misadventure or medical error...population-adjusted AEMT rates have been slowly decreasing." Another study (Rodwin et al. 2020. J Gen Intern Med. 5(7):2099-2106) reported 22,000 preventable deaths per year but only about 7000 were of "patients with greater than 3-month life expectancy."

Critics also claim that many findings in conventional medicine are later shown to be false or cannot be replicated. But Novella (2022 June 8. Science-Based Medicine blog) noted that “The real replication problem, therefore, may be mostly one of perception. The problem with findings that don’t replicate is not that the original study was a false positive, or the new hypothesis was wrong. Again, these are unavoidable and part of the scientific process. The problem is a media culture that presents every new finding as if it is definitely real and we should immediately change our behavior based on the new finding.”

Another claim is that "Only 15 percent of mainstream medicine is based on evidence. False. That estimate was based on a misunderstanding of a study from half a century ago that was never intended to estimate the percentage of treatments based on evidence" (Hall 2014. Op. cit.). See also discussion below in "Scientific Activities and Methods."

Other false claims about conventional medicine include:

• It only uses drugs and surgery, ignoring other non-pharmacologic treatments.

• Doctors are not educated in nutrition. Hall (2014. Op. cit.) wrote, "They understand the science of nutrition, advise their patients based on the available scientific evidence, and refer to dietitians for specific diet plans. CAM providers claim to know more about nutrition, but they usually give pseudoscientific or unfounded diet advice."

• It is alleged that "modern medicine views the patient as a machine to be fixed, just as a mechanic may repair a car...Modern medicine, in this straw-man metaphor, attempts to control or quantify every variable, leading to over medicalization and overtreatment" (Ayers and Kronenfeld 2012. Health Serv Res. 47(5):2081-96).

• Doctors are afraid of the competition. However, "Most doctors already have all the patients they can handle. CAM has only a very small share of the healthcare market. It’s not that doctors are afraid of competition, it’s that they are concerned for their patients’ welfare and don’t like to see them lied to, given ineffective treatments, persuaded to reject effective treatments, and persuaded to risk their health and their money" (Hall 2014. Op. cit.).

• "Doctors are only out to make money." However, "Most doctors go into medicine not because they want to get rich but because they want to help people. There are much better ways to get rich" (ibid.). Medical education is very expensive and it may take many years to repay the debts.

Criticism of science - Hall (2014. Op. cit.) listed five criticisms made against science:

1. "Science doesn't know everything." But science knows this and keeps doing research.

2. "There are other ways of knowing." But only the scientific method leads to reliable knowledge.

3. "Science is only a belief system, just another religion." "Science doesn’t 'believe' anything; it asks and verifies."

4. "Science keeps changing its mind." "Yes, and that’s a good thing. Scientific conclusions are always provisional. Scientists follow the evidence wherever it leads..."

5. "Science is dogmatic." This contradicts #4. "Dogmatism is found in CAM, not in science."

Energy - as used by alternative practitioners, “energy” has a vague, mystical or spiritual quality, not equivalent to any form of energy recognized by science. Some varieties: vital force (homeopathy), qi (chi) (Chinese medicine), prana (Ayurvedic medicine), innate intelligence (chiropractic), human energy field (energy medicine). The use is related to the idea of vitalism, that living things have properties that cannot be explained by their atoms and molecules. "In real science, 'energy' can be quantified and has a precise meaning: it is the capacity to perform work. In human biology, it is measured in Joules, and to 'expend energy' requires burning Joules to accomplish work (e.g., muscle contraction). In other domains of health and wellness, energy is used as a synonym for vigor or vitality, which is still grossly nonspecific" (Tiller 2022. Ten health and wellness buzzwords every skeptic should know. Skeptical Inquirer). See also discussion in the energy medicine section of the article "Homeopathy, naturopathy, energy medicine, and other 'holistic' approaches" (Holistic Part 4).

Holistic - "Alternative therapists try very hard to sell their treatments as holistic. This sounds good and must be an excellent marketing gimmick. Alas, it is not true. There is nothing less holistic than seeing subluxations, yin/yang imbalances, auto-intoxications, energy blockages, etc. as the cause of all illness. Holism is at the heart of all good healthcare; the attempt by alternative practitioners to hijack it is merely a transparent attempt to boost their business" (Ernst 2018 Dec 1. Edzard Ernst blog). Hall (2014. Skeptical Inquirer. 38(6):32-37) wrote, "In medical school, doctors are taught that good medicine requires caring about the whole patient, not just treating the disease. Part of the standard medical history is a 'social history.' Good clinicians consider the patient’s family, lifestyle, job, stresses, education, diet, socioeconomic status, beliefs, and everything about the individual that might have an impact on medical care."

Immune system - some alternative approaches are claimed to regulate the immune system, either to increase it or control it (such as in reducing inflammation). The specific parts of the immune system being affected are usually not specified. Caulfield (2015 Oct 15. Health News Review) wrote: "The immune system is, in fact, ridiculously complex - one of the most complicated systems in the human body...The immune system involves numerous organs, cells and proteins that coordinate to identify and neutralize pathogens...'Boosting' this web of delicately balanced biology is far from easy."

Long history of use - the treatments have stood "the test of time." Ernst (2018 Dec 1. Edzard Ernst blog) wrote, "It is true that most alternative therapies have a long history; but what does that really mean? In my view, it signals but one thing: when these therapies were invented, people had no idea how our body functions; they mostly had speculations, superstitions and myths. It follows, I think, that the treatments in question are built on speculations, superstitions and myths...a long history of usage is no proof of efficacy."

Natural - treatment using "natural" approaches (diet, herbs, manipulation, etc.) is held to be superior to drugs (often referred to as "poisons") and surgery. Chemicals derived from natural sources are regarded as superior to their synthetic equivalents. Ernst (2018 Dec 1. Edzard Ernst blog) wrote "Here we have two fallacies moulded into one. Firstly, not all alternative therapies are natural; secondly, none is entirely safe. There is nothing natural about diluting the Berlin Wall and selling it as a homeopathic remedy. There is nothing natural about forcing a spinal joint beyond its physiological range of motion and calling it spinal manipulation. There is nothing natural about sticking needles into the skin and claiming this re-balances our vital energies."

Opposition to public health measures - some alternative practitioners have opposed measures such as vaccinations, fluoridation of water, and pasteurization of milk. Antivaccination and antifluoridation efforts are described below.

Prevention - as described by Ernst (2017 Jun 5. Edzard Ernst blog), "The strategy requires two little lies, but that’s forgivable considering the good cause, boosting the income of the practitioner: Conventional doctors don’t do prevention. The alternative treatment is an effective preventative. The first statement can be shown to be an obvious lie. All we know about effective disease prevention today comes from conventional medicine and science; nothing originates from the realm of alternative medicine. Remarkably, the most efficacious preventative measure of all times, immunisation, is frequently defamed and neglected by alternative practitioners...I am not aware of any alternative therapy that can effectively prevent any disease." Hall (2014. Op. cit.) noted, "Medical doctors routinely advise patients about weight control, diet, seatbelts and other safety topics, alcohol, drugs, domestic violence, exercise, etc."

Recovery - "Supplements, recovery shakes, massage therapy, stretching, cryotherapy, ice bathing, among others, all claim to promote faster and more effective recovery. Invoking the term is another type of fallacy called '(definitional) ambiguity.' It is misleading or vague language used to deliberately deceive and/or make a claim easier to defend...However, 'recovery' has no clear operational definition or even end point. For instance, does 'recovery' include all facets of biological function, or is it specific to the musculoskeletal system? What about recovery of immune function, hydration, or psychological wellbeing? By itself, the term is ambiguous and can be interpreted to serve any number of functions from person to person" (Tiller 2022. Ten health and wellness buzzwords every skeptic should know. Skeptical Inquirer).

Self-healing - the body is believed to have great healing abilities, which can be stimulated by various approaches (provision of nutrients, meditation, homeopathic remedies, elimination of toxins, correction of subluxations, removal of energy blockages, etc.).

Toxins - deleterious factors from food or the environment are claimed to accumulate (especially in the colon), leading to disease. Methods such as diets, herbs, or colonic irrigation are used to remove them. See the article "Chelation therapy; allergy and arthritis treatments; other miscellaneous topics" (CHELATION AND MISC) for a discussion of detoxification ("detox") approaches.

Treating the root cause of disease - Ernst (2021 Oct 7. Edzard Ernst blog) wrote, "Practitioners of so-called alternative medicine (SCAM) regularly claim with great pride that they treat the ROOT CAUSES of disease. The claim has at least 4 effects:

• It distracts from the true causes of disease which are often multifactorial.

• It attracts customers to SCAM.

• It implies that conventional medicine is at best symptomatic and thus far inferior to SCAM.

• It encourages the patients of SCAM practitioners to turn their backs on mainstream healthcare.

...When a root cause has been eliminated, the disease has been eliminated by its root. Treating a root cause, therefore, means that the disease is permanently cured...Is there any SCAM that cures any disease permanently? I think the answer is NO...Even demonstrably effective forms of SCAM are effective only in terms of alleviating the symptoms." Sampson (2009 Jul 23. Science-Based Medicine blog) wrote, "Claiming to treat the 'underlying cause' of a condition raises the usual straw man argument that modern medicine does not, which of course is untrue. It also implies that there are underlying causes known to them and not to straights."

Treatments are being suppressed by the establishment - allegedly the pharmaceutical industry or conventional medical practitioners are suppressing effective alternative treatments in order to protect their own income. A 2013 survey found that "37% of the sample agreed that the Food and Drug Administration is intentionally suppressing natural cures for cancer because of drug company pressure" (Oliver and Wood 2014. JAMA Intern Med. 174(5):817-8). However, Ernst (2018 Dec 1. Edzard Ernst blog) noted that "whenever ‘Big Pharma’ does smell a fast buck, they do not hesitate to jump on the alternative band-waggon joining them in ripping off the public by flogging dubious supplements, homeopathics, essential oils, vitamins, flower remedies, detox-remedies, etc." Hall (2017 Oct 24. Science-Based Medicine blog) wrote, "When mainstream doctors criticize CAM, it is not to protect their turf. They routinely follow the evidence and stop using treatments or tests that are lucrative when they are found to be ineffective. Their goal is not to maximize income, but to do what is best for their patients."

Alternative practitioners invoke the "Galileo gambit" ("they laughed at Galileo," etc.). Gorski (2017 Mar 20) noted, "For every Galileo, Ignaz Semmelweis, Nicolaus Copernicus, Charles Darwin, Louis Pasteur, etc., whose scientific ideas were either ignored, rejected, or vigorously attacked by the scientific community of his time and then later accepted, there are untold numbers of others whose ideas were either ignored or rejected initially and then were never accepted - and never will be accepted. Why? Because they were wrong! The reason the ideas of Galileo, Semmelweis, Copernicus, Darwin, Pasteur, et al, were ultimately accepted as correct by the scientific community is because they turned out to be correct! Their observations and ideas stood up to repeated observation and scientific experimentation by many scientists in many places over many years."

COMPLEMENTARY AND ALTERNATIVE MEDICINE: SCIENTIFIC CRITIQUE

Some characteristics of pseudoscientific health claims

Ernst (2009. Perspect Biol Med. 52(2):289-303) listed six criteria that distinguish between science and pseudoscience in the area of complementary and alternative medicine:

• Biological implausibility

• Intolerance - "Many CAM proponents are not able to respond appropriately to reasoned criticism."

• Selectivity - "Many CAM proponents will dismiss facts that contradict their own preconceived ideas in favor of anomalous data or anecdotal findings."

• Paranoia - belief that the medical establishment or pharmaceutical industry is working to suppress them

• Inversion of logic - "In arguing their case, proponents of absurd claims often seem to formulate their conclusions first, then select those bits of information that seem to confirm them."

• Misuse of science - use of scientific terms like "nano" or "quantum" "in inappropriate contexts devoid of their actual meanings"

Some other characteristics:

• Nonfalsifiable or irrefutable hypotheses

• Attribute failure to reproduce results to:

failure to perform procedures properly

bias

incorrect attitude

• Unwilling to examine the phenomena closely with carefully controlled experiments

• Reliance on anecdotal evidence, or on data from flawed studies (poor controls, insufficient sample size, etc.). Anecdotal evidence can be very persuasive - especially if it concerns yourself.

• Appeal to popularity - something is true because many people believe it

• Argument from authority rather than evidence - endorsements by doctors, celebrities, panels, etc.

• Confusion of correlation with causality

• Post hoc fallacy - "This fallacy supposes that an event 'X' that is preceded by another event 'Y' must be caused by 'Y.' If we apply a treatment and our patient subsequently gets better, we tend to assume that the improvement was due to our therapy" (Ernst 2020. Wien Klin Wochenschr. 132(9-10):224-7).

• "Special pleading" - less stringent rules of evidence should be applied to its claims

• Claim to be too busy healing patients to pursue verification through research

• Lack of acceptable confirmation of diagnosis before treatment and/or proper followup to confirm healing

• Subjective evaluations or measurements

• Use of pseudomedical jargon: "detoxify," "rejuvenate," "energy," etc. - entities that cannot be measured

• Proposal of a single underlying cause for diverse diseases or conditions

• Appeal to tradition: if idea has been around so long, it must contain some truth

• Charge opponents with being close-minded

• Developed largely by a single charismatic individual

• Charge persecution of unorthodox and revolutionary ideas: "They laughed at..."

• Appeals to vanity of patients: "think for yourself"

• Exaggerated or false advertising claims

• Bogus credentials of practitioners (e.g., degrees from unaccredited institutions)

• Use of secret formulas

• Target desperately ill individuals

• Lack of continuity with other fields of knowledge. Modern scientific medicine is part of an enterprise ranging from physics to astronomy. "Alternative" practices are largely unrelated or even conflicting in their "theories."

• Method can't be tested by standard scientific methods; science is not the only way of knowing

Some things to be aware of in dubious health claims

• Words and phrases: amazing, breakthrough, easy, natural. The field of dietary supplements has its own set of "buzzwords," such as superfood and GMO-free.

• Research (what quality? has it been replicated?)

• Claimed to be effective for wide variety of ailments

• Offers cure

• Immediate results promised

• Questionnaires (nearly everyone ends up with a recommendation for treatment or supplements)

• Invalid diagnostic tests (e.g., hair analysis, applied kinesiology, genetic tests)

Other points

Extraordinary claims demand extraordinary evidence. We are entitled to ask for very strong evidence before we accept ideas that are contradicted by a large amount of prior evidence (see prior probability below).

Crislip (2014 May 16. Science-Based Medicine blog) wrote, "There has never, ever, been an alternative therapy that has changed or been abandoned as a result of quality biomedical trials. Instead those discredited interventions become part of the core curriculum at naturopathic, chiropractic, acupuncture and other schools of pseudo-medicine."

It is claimed that so-called alternative medicine (SCAM) " is so individualized, holistic, subtle, etc., that it defies science. The ‘argument’ is false, and SCAM advocates know it, not least because they regularly and enthusiastically cite those scientific papers that seemingly support their pet therapy" (Ernst 2022 Oct 13. Edzard Ernst blog).

Trained scientists can adopt pseudoscientific methods.

Truth need not lie between extremes.

Absence of disproof is not evidence in favor.

Burden of proof; financial burden of testing. Stalker (1995. Mt Sinai J Med. 62(2):132-43) pointed out that in the competition for limited research funds, we should consider the prior probability that a hypothesis is true, compared to competing hypotheses. Many proposed alternative methods can be given low prior probabilities based on their inconsistency with scientific knowledge or other flaws. Also, since it is possible to find positive cases for virtually any treatment (whether or not it is valid), we cannot assign a high prior probability simply because a practitioner can submit a few "best cases."

Nan et al. (2022. Soc Sci Med. 314:115398) reviewed individual differences in susceptibility to health information. "Our review suggests that subject knowledge, literacy and numeracy, analytical thinking (vs. intuitive thinking), and trust in science confer strong resistance to health misinformation, whereas conspiracy thinking, religiosity, conservative ideology, and conservative party identification are associated with more susceptibility to health misinformation. Demographically, older age and higher educational attainment predict less susceptibility to health misinformation, whereas racial minority status is associated with greater susceptibility. Behaviorally, relying on health professionals or scientists as information sources predicts less susceptibility to health misinformation, whereas social media use is associated with greater susceptibility."

Ernst (2015 July 30. Edzard Ernst blog) criticized the quality of publications: "most (I estimate around 80%) of the articles that currently get published on alternative medicine are useless rubbish. They tend to be either pre-clinical investigations which never get followed up and are thus meaningless, or surveys of no relevance whatsoever, or pilot studies that never are succeeded by more definitive trials, or non-systematic reviews that are wide open to bias and can only mislead the reader."

ADVERSE EFFECTS

Ernst (2019 May 28. Edzard Ernst blog) listed ten ways that "so-called alternative medicine" (SCAM) can cause harm:

1.  "direct harm due to adverse effects such as toxicity of an herbal remedy, stroke after chiropractic manipulation, pneumothorax after acupuncture;

2.  direct harm through the use of bogus diagnostic techniques;

3.  direct harm by using materials from endangered species;

4.  indirect harm through incompetent advice such as recommendation not to immunize or discontinue prescribed medications;

5.  neglect due to using SCAM instead of an effective therapy for a serious condition;

6.  harm due to medicalising trivial states of reduced well-being;

7.  financial harm due to the costs of SCAM;

8.  harm through making a mockery of evidence-based medicine;

9.  harm caused by undermining rational thinking in the society at large;

   10.  harm caused by inhibiting medical progress and research."

In another post, Ernst (2017 Jun 5. Edzard Ernst blog) pointed out that alternative practitioners can instill fear in their patients. "Perhaps the most obvious way to instil fear into people is to tell them that they are affected by a disease or condition they do not have. Many alternative practitioners do exactly that!...These diagnoses have one thing in common: they do not exist. They are figments of the therapist’s imagination. And they have another thing in common: the abnormalities need to be corrected, and – surprise, surprise – the very therapy that the practitioner specialises in happens to be just the ticket for that purpose." Ernst also pointed out that the patient may have "what one might call a medical triviality that does not need any treatment at all but can be dealt with differently, for instance, by issuing some life-style advice or just simple re-assurance that nothing major is amiss." However, the alternative practitioner convinces the patient that treatment is necessary (possibly a lengthy series of treatments).

INTEGRATIVE MEDICINE

Ernst (2021 Jan 9. Edzard Ernst blog) quoted an article by a group of researchers, including Andrew Weil (Alschuler et al. 2022. Explore (NY). 18(2):140-8): "Integrative medicine is defined as healing-oriented medicine that takes account of the whole person, including all aspects of lifestyle. It emphasizes the therapeutic relationship between practitioner and patient, is informed by evidence, and makes use of all appropriate therapies." Ernst commented on the points as follows:

• "IM is healing-oriented medicine: this is a transparently daft platitude...Healing is what medicine has always been and always be aimed at."

• "IM takes account of the whole person: This is the little holistic trick that IM proponents like to adopt. It implies that normal medicine or EBM [evidence-based medicine] is not holistic. This implication is wrong. Any good medicine is holistic..."

• "IM includes all aspects of lifestyle: really, all of them? This is nonsense! Good physicians take into account the RELEVANT lifestyles of their patients...I fear this ‘over the top’ statement merely indicates that those who have conceived it have difficulties differentiating the important from the trivial."

• "IM emphasizes the therapeutic relationship: that’s nice! But so do all other physicians (except perhaps pathologists)."

• "IM is informed by evidence:...finally there emerges a real difference between IM and EBM! While proper medicine is BASED on evidence, IM is merely INFORMED by it. The difference is fundamental, because it allows IM clinicians to use any un- or disproven SCAM [so-called alternative medicine]."

• "IM makes use of all appropriate therapies:...Are the IM fanatics honestly suggesting that conventional doctors use inappropriate therapies?"

"This short analysis confirms yet again that IM is little more than a smokescreen behind which IM advocates try to smuggle nonsense into routine healthcare."

In another post, he quoted the definition adopted at the 13th European Congress for Integrative Medicine (2021 Oct. 31. Edzard Ernst blog): "Integrative medicine combines conventional medicine with evidence-informed complementary medicine and therapies to achieve the optimum health and wellbeing of the patient. Focusing on a holistic, patient-centred approach to healthcare, it takes into consideration the patient’s physical and psychological wellbeing and treats the whole person rather than just the disease." "I find it much worse than the latest US definition...In fact, it turns out to be a poorly disguised bonanza of strawman fallacies combined with ‘bait and switch’ deception."

Novella (2021 Jun 9. Science-Based Medicine blog) discussed a quote in a Medscape commentary: "it seems there are four potential operational features of integrative medicine outlined in this quote: healing-oriented practice, lifestyle interventions, patient-centered care, and addressing physical, mental, and spiritual well-being. The problem is that none of these actually can be distinguished from medicine in general...Reductionist science-based medicine combines all treatment goals, and cures illness whenever possible. Yet is has long been part of the alt med propaganda that mainstream medicine treats only symptoms, while magic-based medicine heals. This marketing claim does not hold up to even the slightest scrutiny. The problem with the other three components, lifestyle interventions, patient-centered care, and addressing physical, mental, and spiritual well-being, is that they are already part of mainstream medicine, where the concepts originated. Integrative medicine (under any of its evolving marketing slogans) did not develop these concepts...By their own definition, therefore, there doesn’t seem to be any legitimate purpose for integrative medicine. It’s just repackaging and rebranding concepts that already exist within mainstream medicine."

In an earlier article (2017 Sep 20. Science-Based Medicine blog), Novella wrote: "When confronted with claims of integrative medicine, you have to always ask yourself, what exactly are they integrating? If mainstream medicine, by its own standards, uses interventions which have been shown to be safe and effective, the only things left to integrate are treatments that have not been shown to be safe and effective. Some of these unproven treatments are also highly implausible, sometimes to the point that they are essentially magic potions and witchcraft."

Gorski (2017 Oct 23. Science-Based Medicine blog) wrote, "I’m always amused at how integrative medicine proponents are always claiming that there are 'several unconventional treatments' that are on the verge of being validated and 'going mainstream,' but somehow none of them ever really do. It would be one thing if this infiltration of alternative medicine into academia were a new thing, but it’s been going on close to 25 years now, and yet it’s always the same old song. As for aromatherapy, yes, humans like good smells. They can lift our spirits. It’s like massage. It feels good when done properly. The problem, as with so much of 'complementary' medicine is when specific medical claims are made for such modalities."

In another article, Gorski (2018 Sep 14. Respectful Insolence blog) wrote: "'Integrative medicine' means, in essence, 'integrating quackery and pseudoscience into medicine'...What is good about it is not unique to it, and what’s unique about it is not good. In other words, the exercise, diet, and lifestyle interventions claimed by integrative medicine are not unique to integrative medicine, but what is unique (e.g., the naturopathy, homeopathy, and the like) isn’t good because it’s quackery." He also noted that "Of course, the problem with 'integrative medicine' is that there really is no science-based standard to tell a physician whether he or she is competent to practice in that area. That’s because, for so many of the modalities that 'integrative medicine' integrates into medicine, there is no science or even scientific plausibility to support them. So it shouldn’t be a surprise that the sort of physician attracted to such a specialty has little fealty to science and is therefore prone to 'practice drift'."

Marcus (2020. J Clin Invest. 130(4):1549-51) wrote, "During the past 20 years, integrative medicine centers that promote the use of alternative therapies were established in more than 70 medical and nursing schools. A survey of hospital websites and interviews with physicians, hospital administrators, and staff revealed that 15 research-intensive medical schools in the United States provide alternative therapies in their integrative medicine centers and affiliated hospitals...Hospital administrators state that they provide alternative therapies in response to consumer interest and that, even if those services don’t generate profits, they build the hospitals’ market share."

Mole (2017 Nov 27. Ars Technica) reported that "More than 60 percent of NIH-supported comprehensive cancer centers in the US include 'integrative medicine' in their services and patient information. And in recent years, the centers’ inclusion of dubious treatments has only grown...For instance, the number of centers providing patients with information on 'healing touch' - a type of 'energy medicine' - increased nearly 30 percent between 2009 and 2016."

Gorski (2017 Oct 11. Respectful Insolence blog) noted that in 2003 Georgetown University "was 'integrating' pseudoscience into its medical school curriculum at every level, starting from day one...Reflexology is taught as fact, along with prescientific medical systems, such as traditional Chinese medicine (TCM), 'energy healing' like reiki and therapeutic touch, and pretty much every 'integrative' quackery you can think of. In 2007, Georgetown partnered with the naturopathy school Bastyr University to train the next generation of integrative medicine practitioners."

In 2017, Susan and Henry Samueli donated $200 million to the University of California, Irvine, for the Susan and Henry Samueli College of Health Sciences, devoted to integrative medicine. A new complex for the college will include the university's medical school.

In 2019, Thomas Jefferson University received a $20 million grant to establish an academic department of integrative medicine, "co-equal to departments of real medical specialties, like surgery, medicine, pediatrics, etc." (Gorski 2019 Feb 27. Respectful Insolence blog).

Bellamy (2016 Dec 8. Science-Based Medicine blog) has argued against board certification for physicians in integrative medicine. First, there is no clear definition of integrative medicine. Second, "the American Board of Integrative Medicine has no publicly available standards for board certification in IM, and, indeed, we don’t even know who runs the ABOIM...State medical boards should be deeply concerned about recognizing a board certification in an ill-defined 'specialty' run by unidentified parties with no published standards. Those standards, whatever they may be, are apparently loose enough to allow physicians to simply summarize their practices in a page or two and take CME [continuing medical education] courses to qualify for the board exam."

FUNCTIONAL MEDICINE

Gorski (2018 Sep 5. Respectful Insolence blog) wrote: "Functional medicine claims to be guided by six core principles:

• An understanding of the biochemical individuality of each human being, based on the concepts of genetic and environmental uniqueness;

• Awareness of the evidence that supports a patient-centered rather than a disease-centered approach to treatment;

• Search for a dynamic balance among the internal and external body, mind, and spirit;

• Familiarity with the web-like interconnections of internal physiological factors;

• Identification of health as a positive vitality not merely the absence of disease emphasizing those factors that encourage the enhancement of a vigorous physiology;

• Promotion of organ reserve as the means to enhance the health span, not just the life span, of each patient.

The above list is the sort of thing that sounds reasonable on the surface but doesn’t stand up to close scrutiny. I could (and would) point out that the 'understanding of the biochemical individuality of each human being, based on the concepts of genetic and environmental uniqueness' seems custom-made to cater to the belief among some of the woo-prone that they are special snowflakes, so utterly unique that treatment must be tailored to their finest uniqueness." He noted, "I’ve often characterized functional medicine as the 'worst of both worlds' because it combines the massive overtesting and overtreatment to which conventional medicine can sometimes be prone with - you guessed it! - quackery. That includes homeopathy, traditional Chinese medicine, and, above all, a boatload of supplements."

He noted that the first principle in the above list "is, in essence, functional medicine’s 'get out of jail free' card for basically anything its practitioners want to do. They can always find ways to justify any form of treatment, be it science-based or quackery, simply by invoking the 'biochemical individuality' of the human being whom they are treating. I also like to remind my readers of my retort to this: Yes, human beings are individuals, and each human being is unique. However, we’re not so unique that our bodies don’t all work pretty much the same way. In other words, in terms of biology, physiology, and yes, systems biology, human beings are far more alike than they are different. If that weren’t the case, modern medicine, developed before we had the tools to probe our genetic individuality, wouldn’t work as well as it does" (Gorski 2018 Dec 17. Science-Based Medicine blog). Concerning the third principle, he wrote, "Basically, functional medicine also fetishizes 'balance' in a way that sounds very much like both ancient Asian and European medicine. It’s a philosophy more than a scientific principle." A different list of principles included: "The body has the ability to heal and prevent nearly all diseases of ageing." Gorski asked, "then why does every single human being eventually die?"

In another post (2018 Sep 14. Respectful Insolence blog) he noted that "Functional medicine claims to encompass endocrinology, metabolism, physiology, and so much more; yet most functional medicine doctors have little or no training in these areas. That’s yet another reason why functional medicine is to me 'making it up as you go along'."

He also wrote that functional medicine practitioners "do lots of lab tests - lots of lab tests! - and act on them all, replenishing nutrients, trace elements, and vitamins whether it’s necessary or not and 'personalizing' treatments based on the 'biochemical individuality' of each individual...from my perspective, functional medicine takes one of worst aspects of conventional medicine, namely its tendency towards overtesting, and puts it on steroids, leading to overtesting to the Nth degree...Basically, what functional medicine really does is to run every lab test under the sun and try to correct abnormal values" (2016 Oct 14. Respectful Insolence blog). He noted that "FM practitioners appear to like to order lab tests related to endocrinology. Of course, 'normal' lab values are usually defined to be a certain number of standard deviations from the population mean, which means that by random chance alone a small percentage of 'normal' people will have an abnormal value of a given laboratory test. When a clinician orders a bunch of laboratory tests on a patient, the likelihood that one of those tests will be 'abnormal' will approach 100% the more tests are ordered. No wonder FM practitioners can always find lab abnormalities to chase" (2016 Apr 11. Science-Based Medicine blog), and "Never mind that in the vast majority of cases it’s unknown or unclear whether these abnormalities have any health significance" (2016 Nov 28. Science-Based Medicine blog). Also, "The reason, of course, that insurance doesn’t cover most of these tests and that 'conventional' physicians won’t order them is because they are unhelpful, useless, and/or not based in science and evidence" (2018 Dec 17. Science-Based Medicine blog).

Gorski acknowledged that "Overall, there are some things that FM gets right, although they are no different than the things every primary care doctor should be getting right, namely emphasizing healthy lifestyles, good nutrition, enough exercise, adequate sleep, cessation of habits known to be deleterious to health (e.g., smoking). They tend to spend more time with patients, which is something that primary care doctors have a harder time doing these days. They emphasize prevention, which is a good thing but again something that good primary care doctors do anyway" (2016 Apr 11. Science-Based Medicine blog).

Sampson (2009 Aug 22. Science-Based Medicine blog) examined claims of Dr. Mark Hyman. "The problem with Hyman’s FM accusation against medicine’s conceptual formation of diseases is that we already incorporate such things as systematic interactions, and have for 100 years or more (internal milieu, etc.,) certainly since discovery of hormones and their feedback mechanisms, and the multiple functions of organs. Even deeper understanding followed the unraveling and understanding of cell membrane and nuclear receptors, intra- and inter-cellular signaling mechanisms, cytokines, hormones, and the genetic controls and external effects on all of them. Hyman makes one think that modern medicine knows little of normal and dysfunctional mechanisms, even though the newest biological drug are based on those same concepts...He also believes our classification of disease by symptoms and signs is wrong: that diseases should be classified by what is out of balance among the seven [or more?] conditions; that disease exists when something is wrong with the functions or interactions of the contents of the seven points. But medicine already classifies diseases according to other criteria such as hereditary, infectious, neoplastic, degenerative, etc. Or, described by organ systems - endocrine, nervous system, etc., as taught in medical schools for 100 years. When the mechanisms are not known, we describe the disorder as a syndrome - a recognized deviation of symptoms and signs. When the mechanisms are discovered, we use more physiological rather than descriptive definitions."

Bellamy (2018 Sep 27. Science-Based Medicine blog) wrote, “In fact, it’s hard to know exactly what functional medicine is, other than a marketing term, partly because there is no detailed explication of its principles and practices anywhere in the medical literature. For that (if it exists at all), physicians, chiropractors, naturopaths and the like must attend the IFM [Institute for Functional Medicine]’s proprietary courses, to the tune of about $15,000, to become ‘certified’ in functional medicine.”

A prominent promoter of functional medicine is the Cleveland Clinic. Li et al. (2018. Surgeon. 16(5):271-7) wrote, "The Centre for Functional Medicine (CFM) was created through the Cleveland Clinic's partnership with the Institute for Functional Medicine. The U.S. Federal Trade Commission found that the Institute for Functional Medicine's founder, Jeffrey Bland, created several corporations that made false and exaggerated claims about their health services...Furthermore, the founder of the CFM, Dr. Mark Hyman, co-authored an anti-vaccination book. Despite being founded by leaders with beliefs that can cause harm to patients, the CFM saw nearly 5300 appointments and had a waiting list of over 1100 individuals since its opening in 2014. In 2016, the Cleveland Clinic stated that the CFM will receive funding to double in size. As a result of the strong media promotion of CFM, patients are unaware of the potential harms and lack of therapeutic effectiveness that come with receiving care from a centre that holds strong non-evidence-based beliefs about medicine."

As described by Bellamy (2018 Sep 27. Science-Based Medicine blog), the American Academy of Family Physicians in 2014 undertook a review of functional medicine in connection with the awarding of continuing medical education credits. “After a literature review, the AAFP made its initial determination that not only was there insufficient evidence to award CME credit, in some cases claims being made for functional medicine were ‘potentially dangerous’...Based on this literature review, the AAFP placed a moratorium on functional medicine courses. A similar evidence review in 2016 came to the same conclusion and the moratorium was extended to 2018.” The moratorium was lifted in 2018 “but only to the extent that these courses give family practice doctors sufficient information to educate interested patients about the topic”; “how-to” courses remained under the moratorium. The head of the AAFP’s Commission on Continuing Professional Development was quoted as saying “given the current lack of evidence, the COCPD does not deem it appropriate to learn how to practice functional medicine or implement related techniques within an AAFP-certified CME activity.”

 REGULATORY AGENCIES INVOLVED IN HEALTH CLAIMS

Food and Drug Administration - regulates content and labeling of foods, drugs, medical devices, and cosmetic products. The role of the FDA is discussed in more detail in the article on dietary supplements.

Federal Trade Commission - regulates advertising and marketing of foods, non-prescription drugs, cosmetics, medical devices, and health care services. Bellamy (2021 May 20. Science-Based Medicine blog) reported that in 2021 the U.S. Supreme Court "ruled that the FTC lacks authority to seek consumer refunds and other monetary relief from scammers."

Postal Inspection Service - regulates products advertised or sold through mail.

State attorneys general

State professional licensing boards. The licensing of various types of alternative practitioners is discussed in the articles dealing with those specific areas (chiropractic, naturopathy, etc.).

ORGANIZATIONS AND WEB SITES PROMOTING CRITICAL EXAMINATION OF ALTERNATIVE CLAIMS

Stephen Barrett, M.D. - Quackwatch (https://quackwatch.org) and related web sites (Chirobase, MLM Watch, Naturowatch, etc.). In 2020 it became part of the Center for Inquiry.       

Society for Science-Based Medicine, and its associated blog (Science-Based Medicine: https://sciencebasedmedicine.org). In 2020 it became part of the Center for Inquiry.

Committee for Skeptical Inquiry (formerly Committee for the Scientific Investigation of Claims of the Paranormal, CSICOP), a program of the Center for Inquiry and publisher of Skeptical Inquirer

Skeptic Society (https://www.skeptic.com/), publisher of Skeptic magazine

Respectful Insolence blog: https://respectfulinsolence.com/

Edzard Ernst blog: http://edzardernst.com/

Harriet Hall's SkepDoc site (https://www.skepdoc.info/). Dr. Hall died in 2023 but the site remains active.

McGill University Office for Science and Society: https://www.mcgill.ca/oss/

LEGAL AND ETHICAL ISSUES

Liability - Gilmour et al. (2011. Pediatrics. 128 Suppl 4:S181-6): "Direct liability...could result if, for instance the physician's referral to a CAM practitioner delayed or eliminated the patient's opportunity to receive needed conventional health care..." "...as knowledge about the appropriateness of various forms of CAM increases, physicians may be held liable if they refer patients for therapies that they know or should know would not benefit the patient."

Gilmour et al. (2011. Pediatrics. 128 Suppl 4:S200-5): "Principles generally applicable when determining medical liability apply to these CAM practitioners as well. Departure from approved practice, although not negligence per se, may underpin a finding of negligence if it is shown that what occurred was not something a reasonable practitioner would have done in similar circumstances. Breach of professional or clinical guidelines or policies, or failure to comply with regulatory requirements, may also provide evidence of negligence...In both Canada and the United States, nonmedical providers (whether allied health or CAM) may have a duty to refer the patient when it becomes apparent that the patient's condition exceeds the provider's skill and training."

Informed consent - Gilmour et al. (2011. Pediatrics. 128 Suppl 4:S187-92): "A physician's duty of care does not necessarily include the obligation to provide information about therapies outside the range of conventional treatment or those not yet supported in the medical literature. However, as CAM therapies such as acupuncture become better studied and their safety and efficacy are established, the scope of disclosure required may expand to include them." Gilmour et al. (2011. Pediatrics. 128 Suppl 4:S200-5): "Failure to obtain informed consent to treatment is a breach of practitioners' standard of care regardless of whether the therapy is conventional or alternative."

Shahvisi (2016. Bioethics. 30(2):69-76) wrote, "... in order for a patient to have given informed consent, she must understand the treatment. I take this to mean that she has sufficient knowledge of its causal mechanisms and has accepted the explanations in which the treatment is implicated. If this interpretation of informed consent is correct, it is unethical for medical professionals to offer or endorse 'alternative medicine' treatments, for which there is no known causal mechanism..."

Commerce - Gavura (2016 Feb 11. Science-Based Medicine blog) noted, "...we argue that the sale of CAM is unethical. CAM can violate all three ethical principles of commercial transactions. In order for commercial transactions to be ethical, they must involve products that work. They must be advertised and promoted fairly and honestly. Finally, these transactions must not harm innocent third parties. Much of CAM fails on one or more of these measures."

Pharmacies - In a typical pharmacy, supplements without scientific support (such as homeopathic products) may be sold alongside genuinely effective remedies. This potentially confuses the customer. Ernst (2022 Nov 11. Edzard Ernst blog) wrote, "By and large, pharmacists continue to go along with the double standards of a) evidence for conventional drugs and b) fairy tales for SCAM [so-called alternative medicine]. In the interest of progress, patient safety, and public health, it is time that pharmacists wake up and remind themselves that they are not commercially orientated shopkeepers but ethical healthcare professionals."

FRAUD AND QUACKERY

"The National Council Against Health Fraud has categorized three problems obscured by the use of doublespeak and weasel words: health misinformation, fraud, and quackery.

• Health misinformation is 'untrue or misleading information,' including erroneous folk beliefs. Marketing research reveals that many people hold health and nutrition misconceptions. These are exploited not only by quacks but even by mainstream advertising. Deeply held misbeliefs can lead to needless injury and death.

• Fraud is best defined as 'an intentional perversion of truth for the purpose of inducing another in reliance upon it to part with some valuable thing.' Not all health-related frauds involve quackery. Billing for medical services not actually rendered is a common example. And not all quackery involves deliberate intent. Some promoters believe that their nostrums are therapeutic.

• Quackery is the practices and pretentions of a quack; a quack is 'anyone who promotes medical schemes or remedies known to be false, or which are unproven, for a profit.' The term can also be applied to products that are promoted with false claims."

(Jarvis 2022. The semantics of quackery. Quackwatch)

Ernst (2017 Jun 10. Edzard Ernst blog) wrote: "Imagine you read somewhere that the condition you are affected by is curable (or at least improvable) by THERAPY XY...Before you now rush to the next health shop or alternative medicine centre, it is worth asking yourself the following questions:

• Is the claim plausible? As a rule of thumb, it is fair to say that, if it sounds too good to be true, it probably is too good to be true.

• What is the evidence for the claim?...With anecdotes, we can never be sure about cause and effect. Therapeutic claims must be based on good evidence, e.g. controlled clinical trials.

• Who is behind the claim?...Check out whether this person is reputable and free of conflicts of interest. An affiliation to a reputable university is usually more convincing than being a director of your own private heath centre.

• Where was the claim published?...It is unthinkable that such an important claim is not made first in a proper, peer-reviewed article in a good medical journal. Go on ‘Medline’, conduct a quick search and find out whether the new findings have been published. If the claim does not come from peer-reviewed journals, forget about it. If it has been published in any journal that has alternative, complementary, integrative or similar terms in its name, take it with a good pinch of salt.

• Is there money involved?...Many new treatments are expensive. So, high costs are not necessarily suspicious. Still, I advise you to be extra cautious in situations where there is the potential for someone to make a fast buck. Financial exploitation is sadly rife in the realm of alternative medicine."

ANTIVACCINATION EFFORTS

For many years some chiropractors and other alternative practitioners have discouraged the use of vaccines. Brown and others (2015. PLoS One. 10(9):e0132562) found that preference for CAM over conventional medicine was associated with a negative attitude toward vaccination. The 2017 National Health Interview survey found that individuals who consulted naturopaths, homeopaths, or chiropractors were less likely to receive flu vaccinations. Ernst (2021 Sep 13. Edzard Ernst blog) pointed out that these practitioners all "claim that vaccines are toxic and their therapeutic options protect against infections."

With the COVID-19 pandemic and strong government recommendations of the new vaccines, the antivaccine movement has grown. Some politicians and even some medical doctors have taken antivaccine positions. A 2021 survey found that "10.1% of primary care physicians do not agree that, in general, vaccines are safe, 9.3% do not agree they are effective, and 8.3% do not agree they are important" (Callahan et al. 2022. Vaccine. 40(18):2588-2603).

Aspects particular to the COVID-19 vaccines will be addressed in another article. However, many of the arguments raised against the new vaccines are the same ones that have been used in past. An unfortunate result of recent antivaccination efforts is that more parents have decided not to have their children vaccinated, and the incidence of vaccine-preventable diseases is increasing (for example, measles outbreaks in 2017-9).

In response to the increasing number of alternative practitioners giving vaccine exemptions, the American Medical Association House of Delegates in 2021 "approved a resolution stating that only licensed physicians should determine whether a person should receive a medical exemption from vaccines" (American Medical Association 2021 Nov 16. Press release). However, even this is not sufficient; "Antivax groups maintain lists of 'vaccine-friendly' doctors willing to write dubious medical exemptions, many of whom advertise on various antivaccine sites their willingness to write medical exemptions" (Gorski 2018 Oct 31. Respectful Insolence blog).

In recent years bills have been introduced in state legislatures that would eliminate school immunizations or expand exemptions.

Antivaccine parents are increasingly seeking religious exemptions from required childhood vaccines. However, “nearly every major religion either encourages its members to vaccinate or is neutral on the subject. The so-called ‘religious exemption’ does not reflect actual religious beliefs, but is a smokescreen that gives anti-vaxxers an excuse to bypass government regulations” (Hall 2020 Sep 8. Science-Based Medicine blog).

Some antivaccine beliefs are tied to conspiracy theories. “But why are conspiracy theories so important to science denial? I’ve always thought that it was because, when you don’t have facts or science on your side, you need to have a reason to explain why the entire medical, scientific, or history establishment believes something different than you do and considers your beliefs to be quackery, pseudoscience, or pseudohistory. So you construct a conspiracy theory that makes you the hero, someone who, with only a few others, shares hidden knowledge that is being suppressed by dark and powerful forces...If you’re an antivaxxer, then of course it’s a cabal consisting of the CDC, the American Academy of Pediatrics, the medical profession, big pharma, and Bill Gates” (Gorski 2020 Sep 28. Science-Based Medicine blog).

A 2021 Cochrane review (Di Pietrantonj et al 2021. Cochrane Database Syst Rev. CD004407), with data from over 20 million children, confirmed the safety and effectiveness of the measles, mumps, and rubella (MMR) vaccine.

Popular antivaccine arguments

1. Vaccines are responsible for autism. This was originally blamed on their content of mercury (see below). The alleged link between vaccinations and autism was largely based on a paper by Wakefield in Lancet in 1998. However, in 2010 Lancet retracted the paper, and a 2011 report charged that the data had been manipulated fraudulently. Since then numerous studies have showed no connection between vaccinations and autism. In the “CDC whistleblower conspiracy theory,” it was alleged that data showing a link between MMR and autism in African-American boys were covered up. However, when appropriate adjustments for confounding variables were made to the raw data, there was no link.

2. Vaccines are responsible for sudden infant death syndrome (SIDS). This was also blamed on mercury. Studies have shown no connection.

3. Chemicals in vaccines produces toxic effects. Most frequently cited was mercury, which is contained in the compound thimerosal (used as a preservative). However, this is being phased out. Other chemicals claimed to produce toxic effects are aluminum, formaldehyde, and propylene glycol.

4. It has been claimed that today's children are "the sickest generation" due to the use of vaccines. In fact, while reported cases of some illnesses have been increasing (in part due to increased screening), many others have decreased. Gorski (2019 Aug 5. Science-Based Medicine blog) noted that "according to the 2015 National Health Interview Survey, among those under 18, more than 85% are in excellent or very good health."

5. Vaccines have been alleged to be linked to homosexuality and to gender dysphoria. There is no evidence for these claims.

6. Childhood vaccines were not tested against saline placebos. However, some vaccines have been tested against saline placebos, and other types of control groups are possible (such as a different antigen or all the components of the vaccine except the antigen). If there is already an effective vaccine for a disease, it would be unethical to test a new vaccine for the same disease against placebo. Gorski (2023 Jun 28. Respectful Insolence blog) wrote, “there is nothing nefarious in there existing a number of vaccines that were tested against older versions of a vaccine against the same disease or that were not tested against a ‘saline placebo.’ That’s literally how ethical clinical trials work. They balance scientific rigor against ethics, which often leads to compromises because ethics always trumps rigorous clinical trial design...Moreover, an ‘appropriate’ placebo for an injectable drug or vaccine does not have to be saline. There are many more placebos that are entirely appropriate to use as a control in a vaccine RCT other than just saline.”

7. The National Childhood Vaccine Injury Act of 1986 provides blanket immunity to all vaccine companies. As noted by Gorski (2023 Jun 12. Science-Based Medicine blog), "This is a common antivax version of events, which leaves out what the bill really did. In the wake of claims that the DPT vaccine had caused neurologic injury to children, there were so many lawsuits against vaccine manufacturers that pharmaceutical companies were strongly considering leaving the US market due to increasing difficulties obtaining liability insurance... The solution agreed upon by Congress...was to set up a special 'no fault' compensation program for those injured by vaccines, the National Vaccine Injury Compensation Program. The law set up a special court with special expertise, commonly called the Vaccine Court, all funded by a tax on each vial of vaccine sold. Complainants denied compensation through the Vaccine Court still have access to federal courts; the law does, however, require that complainants use the Vaccine Court first."

8. Side effects reported in the Vaccine Adverse Event Reporting System (VAERS) show that vaccines are dangerous. However, VAERS “was set up as an early warning system for identification of possible adverse events, but a report to VAERS does not establish that the vaccine caused the reported event” (Hall 2020. Op. cit.). Gorski (2019 Sep 13. Respectful Insolence blog) noted that VAERS is "a system to which anyone can submit a report, and it’s well known that lawyers representing antivaxers wanting to sue for 'vaccine injury' have hopelessly distorted the VAERS database by reporting autism and all sorts of conditions not caused by vaccines."

9. A child’s immune system could be weakened by too many vaccinations ("too many too soon"), so it is better to spread out vaccinations. However, "by spacing out the immunization, patients are at higher risk of contracting vaccine-preventable diseases (VPD) compared to patients on the recommended CDC schedule, thus increasing the risk with little or no benefits" (Simpson M. 2013 Dec 30. Skeptical Raptor blog). A study by Glanz et al. (2018. JAMA. 319(9):906-13) found that children who were ill from diseases not targeted by vaccines were no different in their vaccine antigen exposure from children without illnesses. An accompanying editorial (O'Leary and Maldonado 2018. JAMA. 319(9):870-1) noted that "the actual number of antigens in vaccines is less today - by an order of magnitude - than it was when smallpox vaccine and whole-cell pertussis vaccine were still routinely given to US children." Moreover, "there is little biologic plausibility to support the concept that the human immune system would respond to 300 antigens any less favorably than 100 antigens." Novella (2018 Mar 7. Science-Based Medicine blog) wrote, "vaccines are a tiny, almost insignificant addition to the daily load on our immune systems. They use up a small fraction of our immune resources. It is simply not plausible that the vaccine schedule is overwhelming a child’s immune system. The very concept of 'too many, too soon' is based on nothing but ignorance and fear."

10. Required vaccinations interfere with parents’ right to decide what is best for their children. The counterargument is that parents do not have absolute power over their children, and the government has the right to intervene in the child’s best interest, such as by protecting from communicable diseases. Harrison (2018 Feb 26. Science-Based Medicine blog) wrote, "People often assert their rights; but rights form only one side of the coin, the other is responsibilities. Many vaccines, including against measles, are not routinely given to children younger than 12 months of age, leaving most infants potentially susceptible to several vaccine-preventable diseases. There are also children who, for medical reasons, cannot be vaccinated, e.g., autoimmune disorders, undergoing chemotherapy, etc...And the immune system of others sometimes don’t respond effectively to vaccines. These children are part of our community...As part of our community, our responsibility is to them as well as to our own children."

11. Some vaccines are made using viruses grown in fetal cell lines, which may have originally been obtained from aborted fetuses. However, as Gorski (2020 Feb 19. Respectful Insolence blog) noted, even the Catholic Church “has said that using such vaccines is acceptable given the temporal distance of the ‘evil’ of abortion.”

12. Vaccines can "shed" viruses, endangering nonvaccinated people. However, this only applies to vaccines employing live attenuated viruses, which are rarely used in the U.S. now.  The viruses in such vaccines have been weakened so they would not cause the disease.

13. Dramatic improvements in public health were due to public health measures (such as clean drinking water) and improved medical care rather than to vaccines. However, for those diseases where vaccines are used, the dramatic decreases in illness and death after the introduction of vaccines demonstrates their benefit. Also, Gorski (2018 Nov 9. Respectful Insolence blog) noted, "For preventing the spread of waterborne diseases like cholera, for instance, clean water is essential. But many other vaccine-preventable diseases have little to do with sanitation. Measles, for instance, is primarily spread through air droplets from the respiration and coughing of infected individuals and is incredibly contagious. Only a vaccine can effectively block the spread of measles through a population."

14. Allowing diseases like measles to spread and produce natural "herd immunity" is better than vaccination because it results in predominance of less harmful forms of the disease. However, the diseases for which vaccines are used were always serious ones for some patients.

15. The pharmaceutical industry and medical profession push vaccines for financial reasons. Harrison (2018. Op. cit.) noted, "profit margins on vaccines is very small. Vaccines are biologics, difficult to manufacture. Governments and large insurance companies negotiate prices that allow for small profit margins. Vaccine manufacturers often donate vaccines to Third World nations. Vaccine sales worldwide account for only about 2 to 3 percent of world-wide pharmaceutical sales...Doctors sometimes lose money on vaccines, break even, or manage only a very small profit.  And doctors give them because their professional organizations, research, and the CDC recommend them...focusing on profits by antivaccinationists is both illogical and devoid of common sense as everything sold in the United States is for-profit...The question is not whether sales of any product result in profit; but whether the product confers some benefit, its cost-benefit ratio."

Prominent antivaccine individuals and organizations

• Robert F. Kennedy, Jr. and Children's Health Defense (previously World Mercury Project)

• Physicians for Informed Consent

• Association of American Physicians and Surgeons and the Journal of American Physicians and Surgeons

• Age of Autism - "a site that hosts the blogs of the ableist leaders in the field of anti-vaccination crankery and has little to do with actual autism other than the false claim that vaccines cause autism" (RationalWiki 2023. Age of Autism)

• Barbara Loe Fisher and National Vaccine Information Center. A major funder is Joseph Mercola, D.O., a marketer of dietary supplements.

• Del Bigtree (television and film producer) and Informed Consent Action Network

• Sherri Tenpenny (osteopathic physician) and Vaccine Choices

• Andrew Wakefield - physician who promoted the alleged link to autism (see above) and who continues to promote anti-vaccine ideas

• Senator Rand Paul (R-KY)

• Steve Kirsch (entrepreneur)

• Gayle DeLong (economist, City University of New York) (died 2022)

• Vaccine Re-education Discussion Forum (Facebook group)

• Ty and Charlene Bollinger - promoters of alternative cancer treatments, more recently turned to antivaccine activity

• Jennifer Margulis - home birth advocate and critic of modern medicine; her PhD is in English

• Brownstone Institute - right-wing group formed in 2020 to oppose public health measures during the COVID pandemic

ANTIFLUORIDATION EFFORTS

Fluoridation of drinking water is generally considered by the dental and medical communities to be a great public health achievement. However, opposition remains.

As reported by Hall (2021. Skeptical Inquirer. 45(3):18-20), some of the most common arguments against fluoridation are:

"1. Fluoride causes fluorosis (tooth discoloration), mainly at higher doses.

2. Additional sources of fluoride (toothpaste, etc.) can lead to higher doses than intended.

3. Water fluoridation forces medication on everyone, not just those who will benefit.

4. Other ways of providing fluoride are equally effective."

Among the points made by Hall (2019. Skeptic. 24(4):4-5) were:

• "Fluorosis should not occur at currently recommended levels of water fluoridation."

• "Fluoridation is the most cost-effective way to prevent tooth decay. Every $1 invested in fluoridation saves $38 in treating dental problems."

• "Water fluoridation is a cost-effective, efficient way to reduce tooth decay in populations, but it is not the only way. Where it is not available, parents have to be educated to know that their children need fluoride supplements, and poor families may not be able to afford supplements or dental treatment. If opponents of fluoridation cared about the welfare of children, they would advocate other ways of getting fluoride to children, like adding fluoride to table salt, or they would offer to subsidize free supplements and free dental care for poor children."

Some studies have suggested a link between maternal fluoride ingestion and lower IQ scores of the children, but these were mostly at very high levels of fluoride found naturally in the water in some locations. A 2019 Canadian study reported an effect at levels similar to those used in fluoridation, but the study had a number of serious flaws. Hall (ibid) wrote, "The bottom line is that high doses of fluoride can be toxic, but the recommended concentration (0.7 mg/L) used in community water fluoridation is not harmful or toxic. Public water fluoridation is not going to decrease your children’s IQs."

Critical Thinking in Evaluation of Medical Claims

PHILOSOPHICAL ISSUES

Is there more than one system or approach to truth? More than one set of realities?

British Medical Association report (1986): "...orthodox medicine will not exclude a treatment because its mode of action is not understood. There is thus no logical class of 'alternative therapies': there are only therapies with and without good evidence for their efficacy."

Fontanarosa and Lundberg (1998. JAMA. 280(18):1618-9): “There is no alternative medicine. There is only scientifically proven, evidence-based medicine supported by solid data or unproven medicine, for which scientific evidence is lacking. Whether a therapeutic practice is ‘Eastern’ or ‘Western,’ is unconventional or mainstream, or involves mind-body techniques or molecular genetics is largely irrelevant except for historical purposes and cultural interest.”

Novella (2018 Jun 4. Neurologica blog) wrote, "One form of science rejection is being called ‘indigenous ways of knowing’ (IWK), which refers to the traditions and culture of native people, typically historically oppressed by Western aggression and colonialism...The problem with taking post-modernist principles to [sic] far in this way is that science and rigorous scholarship are not just cultural ideas, they are methods that have demonstrable value, and have been shown to work. As I like to say, there is nothing magical or even cultural about science. Science is a set of methods used to make our conclusions more reliable...It is critical to understand that, by definition, any ‘alternative’ to science or ‘other way of knowing,’ therefore, involves cherry picking evidence, using bad logic, using vague definitions, making poor observations complicated by confounding variables, or operating in an opaque rather than transparent manner. None of those are good things, no matter what culture you come from...IWK usually involves calling current superstitions and spiritual beliefs 'wisdom' and then exaggerating how ancient that wisdom is, coupled with the 'argument from antiquity.' Just because an idea has been around a long time, doesn’t make it true."

NATURE OF SCIENCE

Based on natural law (as opposed to supernatural)

Tested against the empirical world

• Falsifiability - statements are capable of being shown to be false, if they are in fact false

• Confirmation vs. proof: scientific ideas are not proven to be true (as in mathematics or logic); rather, they may be confirmed through new evidence that is in support

• Self-correcting

Tentative: scientists do not claim to know with certainty that an idea is correct; they admit that new findings could show that the idea is incorrect

Predictive: a good scientific idea predicts results from experiments or observations that have not yet been done

Scientific theories unify a diversity of results

Fruitful: ideas lead to additional discoveries

SCIENTIFIC ACTIVITIES AND METHODS

Many medical advances come through controlled studies (such as laboratory, animal, clinical, and epidemiological studies), which can be contrasted with anecdotal and case studies.

It is sometimes claimed that only 10 to 20% of medical procedures have been shown to be effective. This is a myth, based on: 1) data from a few rural British physicians in 1960-1. 2) other unpublished estimates. Imrie and Ramey (2000. Complement Ther Med. 8(2):123-6) summarized more recent studies showing that the fraction of interventions that were evidence-based ranged from 45% to 97%, depending on the specialty.

Some terms that arise in clinical studies:

• block randomization - subjects are divided into groups (blocks), and then randomized within the blocks. This has two possible advantages. For small numbers of subjects, it ensures more equal numbers of subjects in control and treatment groups. Patients may also be put into blocks based on characteristics that might affect the results (such as severity of disease), and this ensures that controls and treated are similar at baseline. This is referred to as stratification.confidence interval - expresses the estimated range of effects based on the data. Usually a 95% value is employed, in which case we have 95% confidence that the true value is within the stated range.

• intention-to-treat analysis - the data from all subjects are included for the groups to which they were assigned, even if they do not complete the study. Eliminates potential artifacts that could arise if the treatment (or lack of treatment) causes unfavorable effects that lead to dropouts.

• odds ratio - ratio of the odds of an event happening in the experimental group to that for the control group. If the odds are low, it is similar to relative risk, the ratio of the risk in the experimental group to that in the control group. For both of these, values of 1 indicate no difference.

• power calculation - determines the number of patients needed to detect an effect of a given size with a given level of statistical significance.

• primary and secondary outcomes - the primary outcome is the main result that is being tested. Along the way information is also collected on other outcomes, and these data can also be analyzed. Ideally, all of these (as well as the subgroups) would be defined prior to the start of the study; otherwise there is potential bias in selecting from many possible subgroups and outcomes those that give a preferred result.

• subgroup analysis - in addition to comparing data for the entire groups of controls and treated subjects, data from selected portions (such as only one sex, a certain age group, or a group with a certain medical history) are analyzed.

• type I error - false positive; incorrectly rejecting the null hypothesis, concluding that there is an effect when actually there is not

• type II error - false negative; incorrectly accepting the null hypothesis, concluding that there is no effect when actually there is one.

• visual analog scale - a subject puts a mark on a scale (such as from 1 to 10) to indicate the level of a subjective evaluation (such as the amount of pain). This results in numerical data that can be analyzed statistically.

Hardy (2006. Focus Alternat Complement Ther. 11(2):87-8) pointed out that "Clinical trials of conditions that have a large placebo response or do not uniformly respond to conventional therapy (such as depression) should have both a positive control group (to show that a known effective therapy would have a clear effect) and a negative control group (to control for placebo effects)."

Some important aspects of sound scientific studies:

• Statistical validity. However, "statistical significance between groups may occur with very small differences that are clinically meaningless" (McGlothlin and Lewis 2014. JAMA. 312(13):1342-3).

• Confirmation by independent observers

• Publication in peer-reviewed journals

SOME TYPES OF CLINICAL STUDIES

Retrospective studies (looking at events that have already occurred)

• International studies: compare groups in different countries

• Migrant studies: compare people who move from one country to another

• Case-control studies: compare people with disease (but otherwise similar) to people without disease

Prospective studies (collecting data from events that occur after the start of the study)

• Cohort studies: start with healthy population and follow through time

• Prevention studies: give treatment to healthy population

• Intervention studies: give treatment after onset of disease

• Crossover design: at some point in the study the subjects switch groups

• Single- and double-blind: in a single-blind study, the participant does not know which group he or she belongs to. In a double-blind study, the person evaluating the outcome also does not know the group assignment.

• Secondary prevention studies: test of the treatment in participants that are in an early stage of a disease, or to prevent recurrence of the disease.

• Preference trials "may represent a useful approach...if patient randomization is difficult or inappropriate...participants with no treatment preferences are randomized to the available treatment options but those with preferences received their preferred treatment" (Staud 2011. Rheum Dis Clin North Am. 37(1):9-17).

• Pragmatic trials: test the intervention under conditions more similar to actual practice, for example, by relaxing the selection criteria. Ernst (2010. Br J Gen Pract. 60(571):135) noted "Pragmatic studies can, of course, be very useful - but are primarily for testing how well a treatment performs in real life, once rigorous studies have demonstrated it to be effective under well-controlled conditions." Gorski (2022 Apr 11. Science-Based Medicine blog) added, "Remember, the idea behind pragmatic trials is to assess how well a treatment validated in RCTs [randomized controlled trials] works 'in the wild,' so to speak, not to determine whether it does work in the first place. Doing a pragmatic trial of a treatment that has never been validated as efficacious for anything is, as I so frequently say, putting the proverbial cart before the horse. Basically, pragmatic trials are very prone to highly 'positive' results due to placebo effects, because there is no placebo control."

• Pilot studies: "A pilot study is a small scale preliminary study conducted in order to evaluate feasibility, time, cost, adverse events, and improve upon the study design prior to performance of a full-scale research project. Yet, the elementary preconditions are not fulfilled by the plethora of SCAM [so-called alternative medicine] pilot studies that are currently being published. True pilot studies of SCAM are, in fact, very rare. The reason for the abundance of pseudo-pilots is obvious: they can easily be interpreted as showing encouragingly positive results for whatever SCAM is being tested. Subsequently, SCAM proponents can mislead the public by claiming that there are plenty of positive studies and therefore their SCAM is supported by sound evidence" (Ernst 2020 Dec 5. Edzard Ernst blog)..

• N-of-1 trial: a single patient is given both treatment and control; a crossover study with one subject.

Case-control studies and cohort studies are examples of observational studies, in contrast to experimental studies. They may indicate correlations, but the correlation does not necessarily indicate causation. Hall (2021. Skeptical Inquirer. 45(5):19-21) wrote: "The Bradford Hill criteria for causation is a list of nine principles that can help establish whether a correlation represents causation. They are:

1. Strength (effect size)

2. Consistency (reproducibility)

3. Specificity

4. Temporality (effect occurs after cause)

5. Biological gradient (dose-response relationship)

6. Plausibility

7. Coherence between different kinds of evidence

8. Experimental confirmation

9. Analogy with other associations

Some authors add a tenth principle: Reversibility (if the cause is deleted, the effect should disappear).”

Ernst has discussed the "safe-study" design or "A + B versus B" design, which is almost guaranteed to produce positive results. One group gets usual care (B), the other usual care plus the test treatment (A). Because of placebo effects, subjects tend to report better results with A + B even if A is ineffective.

Equivalence trials: Ernst (2020 Dec 5. Edzard Ernst blog) noted that "It is also possible to mislead people with studies which do not test whether an experimental treatment is superior to another one (often called superiority trials), but which assess whether it is equivalent to a therapy that is generally accepted to be effective. The idea is that, if both treatments produce similarly positive results, both must be effective.  Such trials are called non-superiority or equivalence trials, and they offer a wide range of possibilities for misleading us. If, for example, such a trial has not enough patients, it might show no difference where, in fact, there is one." It is also possible to underdose the control patients, making it seem that the test treatment is equally good.

Another pitfall discussed by Ernst is that a trial can be "de-randomized" if the therapist might behave differently toward the treatment and control groups, affecting their expectations. "There are several ways of minimising this de-randomisation phenomenon. But the only sure way to avoid this de-randomisation is to blind not just the patient but also the therapists (and to check whether both remained blind throughout the study). And that is often not possible or exceedingly difficult in trials of SCAM [so-called alternative medicine]. Therefore, I suggest we should always keep de-randomisation in mind. Whenever we are confronted with an RCT that suggest a result that is less than plausible, de-randomisation might be a possible explanation."

Bausell (2009. Eval Health Prof. 32(4):349-69) evaluated 45 trials of CAM published in high-impact journals. Of those meeting three criteria for validity, only 2 (8%) had positive results. However, for those deficient in one or more aspects, 56% had positive results.

CONSORT (Consolidated Standards of Reporting Trials): “The CONSORT statement is a 25-item checklist and a flow diagram which is an evidence-based, minimum set of recommendations for reporting randomized trials to alleviate the problems arising from inadequate reporting of RCTs. The CONSORT statement improves the ability to assess validity of clinical trials and also permits better decisions regarding inclusion and possibly weighting of a study within systematic reviews and meta-analyses” (Syed 2021 Nov 5. Students 4 Best Evidence blog).

Evidence-based medicine (EBM) “is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research” (Sackett et al. 1996. BMJ. 312(7023):71-2).

However, Ernst (2009. Perspect Biol Med. 52(2):289-303) pointed out that "EBM does not address the question of biological plausibility." To deal with this problem, science-based medicine includes “the use of the best scientific evidence available, in the light of our cumulative scientific knowledge from all relevant disciplines, in evaluating health claims, practices, and products” (Science-Based Medicine 2008 Jan 1. Announcing the Science-Based Medicine blog).

Novella (2022 Sep 7. Science-Based Medicine blog) wrote, "One way to define Science-Based Medicine is by how we define what it means for a science-based treatment to work. It means that when we look critically at the totality of scientific evidence, it is more likely than not (to some reasonable level of confidence) that there is a specific measurable physiological effect from the treatment. We spend a lot of time fleshing out the details of how to do such an analysis. Here is a quick summary: First, the treatment has to be at least reasonably plausible (a factor that distinguishes SBM from evidence-based medicine – EBM). That does not mean we have to know the precise mechanism of action but it should mean the treatment does not break fundamental laws of physics, or defy a basic understanding of chemistry or physiology, or necessarily introduces a purely magical phenomenon. We also need high-quality clinical evidence for efficacy. This means that there are experimental trials which isolate the alleged phenomenon as completely as possible from all other confounding factors. Generally in medicine we refer to these confounding factors as placebo effects – an apparent response to the non-specific aspects of being treated, and therefore such trials are called placebo-controlled. Before we consider a medical phenomenon to be real I would argue that we need such placebo-controlled trials that are sufficiently rigorous in their design and execution that show a statistically significant and clinically meaningful objective outcome (as objective as possible) that sufficiently replicates. Replication must also be independent – not just confined to one lab, set of researchers, or country. Further, the effect persists over time (does not vanish due to the decline effect), and persists when we look at only the highest quality studies. The effect also persists when controlled for publication bias. I would also now include the stipulation that the effect persists when you only look at studies that have been pre-registered, in order to minimize the effects of P-hacking [looking at multiple comparisons or subgroups in order to find one that appears to be statistically significant]."

Atwood (2008 Feb 8. Science-Based Medicine blog) wrote, "To many in this era of EBM it seems self-evident that all unproven methods, including homeopathy, should be subjected to such scrutiny. After all, the anecdotal impressions that are typically the bases for such claims are laden with the very biases that blinded RCTs were devised to overcome. This opinion, however, is naive. Some claims are so implausible that clinical trials tend to confuse, rather than clarify the issue. Human trials are messy. It is impossible to make them rigorous in ways that are comparable to laboratory experiments. Compared to laboratory investigations, clinical trials are necessarily less powered and more prone to numerous other sources of error: biases, whether conscious or not, causing or resulting from non-comparable experimental and control groups, cuing of subjects, post-hoc analyses, multiple testing artifacts, unrecognized confounding of data due to subjects’ own motivations, non-publication of results, inappropriate statistical analyses, conclusions that don’t follow from the data, inappropriate pooling of non-significant data from several, small studies to produce an aggregate that appears statistically significant, fraud, and more."

REVIEWS AND META-ANALYSES

Narrative reviews and systematic reviews: "Narrative reviews tend to be mainly descriptive, do not involve a systematic search of the literature, and thereby often focus on a subset of studies in an area chosen based on availability or author selection. Thus narrative reviews while informative, can often include an element of selection bias...Systematic reviews, as the name implies, typically involve a detailed and comprehensive plan and search strategy derived a priori, with the goal of reducing bias by identifying, appraising, and synthesizing all relevant studies on a particular topic. Often, systematic reviews include a meta-analysis component..." (Uman 2011. J Can Acad Child Adolesc Psychiatry. 20(1):57–9).

Umbrella reviews: "Umbrella reviews, which are systematic reviews of previous ones, provide an overall assessment of the information available on a specific topic. Umbrella reviews reach intuitive conclusions by conducting systematic reviews with a consistent approach to variables, allowing for comprehensive analysis integrating previously published systematic reviews or meta-analyses. An umbrella review can also be used to quickly assess a large amount of evidence and compare the findings of previous systematic reviews...Umbrella reviews obviously suffer from a lack of quality or available data in the included studies and reviews. The concept of umbrella reviews is rather new and relatively unexplored. It raises the issue of heterogeneity when combining systematic reviews with different conditions, indicating that the quality of each systematic review remains a concern" (Choi and Kang 2022. Korean J Pain. 35(2):127-8).

Scoping reviews: "scoping reviews are an ideal tool to determine the scope or coverage of a body of literature on a given topic and give clear indication of the volume of literature and studies available as well as an overview (broad or detailed) of its focus. Scoping reviews are useful for examining emerging evidence when it is still unclear what other, more specific questions can be posed and valuably addressed by a more precise systematic review. They can report on the types of evidence that address and inform practice in the field and the way the research has been conducted" (Munn et al. 2018. BMC Med Res Methodol. 18(1):143).

Meta-analysis: attempts to draw conclusions by analysis of previously published studies, with critical consideration of their methodological strengths and weaknesses. The Jadad scale (see below) is frequently used, evaluating whether the study includes statements and adequate descriptions of: randomization (0 to 2 points), double-blinding (0 to 2 points), and treatment of dropouts and withdrawals (0 to 1 point). However, it has been pointed out that the scale may reward reporting quality rather than methodological quality. Methods for dealing with bias in meta-analyses (such as presence of asymmetry in funnel plots) have been described (Sterne et al. 2001. BMJ. 323(7304):101-5).

W. Sampson (2006 May. Healthfraud e-mail discussion list) pointed out that "The Cochrane reviews of anomalous methods are generally performed by advocates and practitioners of the methods investigated, furthering the chances for positive bias...When they report no effect, the interpretations are often muted: 'results are mixed...,' 'conflicting,' 'indeterminate,' etc."

Ioannidis (2016. Milbank Q. 94(3):485-514) wrote, "The production of systematic reviews and meta-analyses has reached epidemic proportions. Possibly, the large majority of produced systematic reviews and meta-analyses are unnecessary, misleading, and/or conflicted." Ernst (2018 Mar 16. Edzard Ernst blog) commented, "Obviously, Ioannidis did not have alternative medicine in mind when he researched and published this article. But he easily could have! Virtually everything he stated in his paper does apply to it. In some areas of alternative medicine, things are even worse than Ioannidis describes."

Network meta-analysis: "a meta-analysis in which multiple treatments (that is, three or more) are being compared using both direct comparisons of interventions within randomized controlled trials and indirect comparisons across trials based on a common comparator" (Li et al. 2011. BMC Med. 9:79).

GRADES OF EVIDENCE FOR THE PURPORTED QUALITY OF STUDY DESIGN

(U.S. Preventive Services Task Force, as cited in Concato et al. (2000. N Engl J Med. 342(25):1887-92)

I       Evidence obtained from at least one properly randomized, controlled trial.

II-1   Evidence obtained from well-designed trials without randomization.

II-2   Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group.

II-3   Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments (such as the results of the introduction of penicillin treatment in the 1940s) could also be regarded as this type of evidence.

III     Opinions of respected authorities, based on clinical experience; descriptive studies and case reports; or reports of expert committees.

LEVELS OF EVIDENCE

Sackett (1989. Chest. 95(2 Suppl):2S-4S) described the following levels:

I       “Randomized trials with sufficient patient numbers that there are low false-positive (α) and low false-negative (β) errors.”

II      “Randomized trials with high false-positive (α) and/or high false-negative (β) errors.“

III     “Nonrandomized, concurrent cohort comparisons between contemporaneously treated patients.”

IV     “Nonrandomized, historical cohort comparisons between current patient groups receiving the experimental treatment and previously treated groups treated in another manner.”

V      “Case studies without control groups.”

JADAD SCALE

Give one point for:

• Study described as randomized

• Method for randomizing described and appropriate

• Study described as double-blind

• Method of double-blinding described and appropriate

• Description of withdrawals and dropouts

Subtract one point for:

• Method for randomization described and inappropriate

• Method for double-blinding described and inappropriate

SKEPTICISM AND OPEN-MINDEDNESS

There are dangers of being too gullible or too skeptical (see type I and type II errors above).

Prejudice vs. postjudice: rejection of evidence after consideration is not close-mindedness

Open mind vs. empty mind: when considering a new idea we do not need to abandon previously accumulated evidence that is relevant.

Lack of mechanism vs. test of evidence: science does not reject an approach simply because its mechanism is unknown; the critical element is whether there is evidence that it works.

REVIEWS OF COMPLEMENTARY AND ALTERNATIVE MEDICINE FOR DIFFERENT CONDITIONS

This section includes reviews considering the prevalence, popular forms, and evidence in support for diverse forms of complementary and alternative medicine applied to particular conditions. Use of individual methods, and of multiple methods within a single class of approaches (e.g., supplements, traditional Chinese medicine) are discussed in the articles on those methods. In addition, reviews in some areas, such as cancer and arthritis, are listed in articles dealing with those topics.

Alopecia: Hosking et al. 2019. Skin Appendage Disord. 5(2):72-89: "Although there are a variety of CAM treatment options on the market for alopecia, only a few are backed by multiple randomized controlled trials."

Arrhythmias:

• Brenyo and Aktas 2014. Am J Cardiol. 113(5):897-903: "Many of these complementary and alternative medical (CAM) remedies have antiarrhythmic properties similar to prescription antiarrhythmic agents and if taken inappropriately, particularly in combination with prescription antiarrhythmic agents, may prove harmful. Morever, many CAM therapies can alter the metabolism of other evidence-based heart failure or antiarrhythmic agents resulting in avoidable toxicity and adverse clinical events."

• Kanmanthareddy et al. 2015. J Thorac Dis. 7(2):185-92: "Several studies have shown improvement in AF [atrial fibrillation] symptoms with yoga therapy, acupuncture and biofeedback. There are also several herbal medicine and supplements such as omega-3 fatty acids, antioxidant vitamins, barberry, motherwort, cinchona, Shensongyangxin, hawthorn, Kella and Wenxin Keli that have been evaluated as potential therapeutic options in AF. These studies are however limited by small sample sizes with mixed results. Besides the pharmacological action, metabolism, interactions with other medications and the adverse effects of the herbal medications and supplements remain poorly understood."

Colds: Ware 2017 Jan 17 (updated Dec 2022). Evidently Cochrane: "There is reliable evidence that vitamin D supplements help prevent upper respiratory tract infections, especially in those who have a deficiency... Vitamin C supplementation may have little or no effect on reducing the chance of getting a cold in the general population, though it may be useful for people who do brief periods of extreme physical exercise...The Cochrane Review Heated, humidified air for the common cold (August 2017) concluded that the little evidence available shows that there may be little to no benefit or harm of inhaling heated humified air...There is a lack of research evidence on the effects of garlic in people with colds...Echinacea products have not been shown to provide benefits for treating colds, although, it is possible there is a weak benefit from some Echinacea products."

Colic: Perry et al. 2019. Syst Rev. 8(1):271: "Sixteen systematic reviews were identified. Probiotics, fennel extract and spinal manipulation show promise to alleviate symptoms of colic, although some concerns remain. Acupuncture and soy are currently not recommended. The majority of the reviews were assessed as having high or unclear risk of bias and low confidence in the findings."

Constipation: Wang and Yin 2015. Evidence-Based Complement Altern Med. 2015:396396: "Acupuncture or electroacupuncture was found to be most commonly used for constipation among these complementary and alternative therapies, followed by herbal medicine. Although only a small number of clinical studies are flawless, our review of the literature seems to suggest that acupuncture or electroacupuncture and herbal medicine are effective in treating constipation, whereas findings on massage and moxibustion are inconclusive."

Dermatology:

• Sawni and Singh 2013.  Pediatr Rev. 34(2):91-3: "Some emerging data suggests that dietary modification (in particular, decreasing the glycemic index and glycemic load), as well as supplementation with omega-3 essential fatty acids, may be beneficial in acne management. A few small pilot studies have reported efficacy of some herbs and nutritional supplements, traditional Chinese medicine, ayurvedic herbs, and phototherapy in the treatment of acne."

• Cao et al. 2015. Cochrane Database Syst Rev. CD009436: "here is some low-quality evidence from single trials that LGLD [low glycemic load diet], tea tree oil, and bee venom may reduce total skin lesions in acne vulgaris, but there is a lack of evidence from the current review to support the use of other CAMs, such as herbal medicine, acupuncture, or wet-cupping therapy, for the treatment of this condition. There is a potential for adverse effects from herbal medicines; however, future studies need to assess the safety of all of these CAM therapies."

• Gamret et al. 2018.  JAMA Dermatol. 154(11):1330-7: "The CAM therapies with the most robust evidence of efficacy for treatment of psoriasis are indigo naturalis, curcumin, dietary modification, fish oil, meditation, and acupuncture." However, Ernst (2018 Sep 10. Edzard Ernst blog) was critical of the conclusions, particularly concerning acupuncture. "Had they critically assessed the quality of the primary studies...they would have had to admit that these studies are too dubious for any firm conclusion."

• Jones et al. 2020. JAAD Int. 2:76-93: "Based on our quantitative findings we conclude that there is insufficient evidence to support the efficacy and the recommendation of CAM for acne, AD [atopic dermatitis], and psoriasis."

Diabetes: Diabetes Canada Clinical Practice Guidelines Expert Committee 2018. Can J Diabetes. 42 Suppl 1:S154-61: "Anywhere from 25% to 57% of people with diabetes report using complementary or alternative medicine. Some natural health products have shown a lowering of A1C by ≥0.5% in trials lasting at least 3 months in adults with type 2 diabetes, but most are single, small trials that require further large-scale evaluations before they can be recommended for widespread use in diabetes. A few more commonly used natural health products for diabetes have been studied in larger randomized controlled trials and/or meta-analyses refuting the popular belief of benefit of these compounds...There is insufficient evidence to make a recommendation regarding efficacy and safety of complementary or alternative medicine for individuals with diabetes."

Eating disorders: Fogarty et al. 2016. Eat Behav. 21:179-88: "There may be a potential role for the CAM treatment relaxation, massage and bright light therapy, in the treatment of depression for those with Bulimia Nervosa and a potential role for the CAM treatments acupuncture and relaxation, in the treatment of State Anxiety, for those with an eating disorder. The review found no evidence that CAM treatment has a substantial beneficial effect on the eating disorder itself and thus CAM treatments should be provided as adjunctive treatments."

Fibromyalgia: Langhorst et al. 2014. Evid Based Complement Alternat Med. 2014:408436: "In summary, almost every FMS [fibromyalgia syndrome] patient had used at least one CAM therapy for the management of FMS. In an Internet sample of US American FMS patients, the frequencies were slightly higher. CAM use in FMS patients is associated with younger age, female gender, and higher overall disease burden...Contrary to Germany and Israel, where some CAM therapies were recommended, no CAM treatment was recommended according to the Canadian guidelines."

Gastrointestinal disease (see also irritable bowel syndrome): Dossett et al. 2017. Prim Care. 44(2):265-80: “Promising results have been achieved with mind-body therapies, acupuncture, diet, and some dietary supplements including probiotics and specific herbs in distinct gastrointestinal conditions.”

Glaucoma: Marando and Chen 2023. Semin Ophthalmol. 38(1):85-91: “In summary, the literature suggests that there are transient and/or theoretical benefits of complementary and alternative medicine for glaucoma care; however, the overall evidence to support their use is weak.”

Headache:

• Millstine et al. 2017. BMJ. 357:j1805: “The overall quality of the evidence for CIM [complementary and integrative medicine] in headache management is generally low and occasionally moderate. Available evidence suggests that traditional Chinese medicine including acupuncture, massage, yoga, biofeedback, and meditation have a positive effect on migraine and tension headaches. Spinal manipulation, chiropractic care, some supplements and botanicals, diet alteration, and hydrotherapy may also be beneficial in migraine headache. CIM has not been studied or it is not effective for cluster headache.” However, Ernst (2017 May 17. Edzard Ernst blog) was quite critical of this review, noting a number of problems. “Moreover, the article is badly researched, cherry-picked, poorly constructed, devoid of critical input, and poorly written.”

• Zhang et al. 2017. Headache. 57(8):122842: Reported results from 2012 National Health Survey. About 38% of headache sufferers used complementary and alternative medicine, but only 3% used it specifically for headache. Most frequently used approaches were manipulative therapy, herbs, and mind-body medicine.

Heart failure: Chow et al. 2023. Circulation. 147(2):e4-e30: "There is substantial interest in and wide use of CAM in patients with HF. However, these interventions are being used with limited to no high-quality evidence of efficacy...Although there is substantial promise for some of these CAM interventions, there are likely many agents being used providing no benefit or even resulting in unintended harm."

Hepatitis C: Marzio and Fenkel 2014. World J Hepatol. 6(1):9-16: “Some CAM has demonstrated therapeutic potential in chronic hepatitis C treatment. Unfortunately, some CAM has been shown to have the potential to cause drug-induced liver injury...At this time, there is no firm evidence supporting complementary and alternative medications for hepatitis C virus infection.”

Hypertension: Ernst 2020 Aug 24. Edzard Ernst blog: Ernst found 94 systematic reviews since his previous review in 2005. Most of the tested methods “seem to have positive effects; in many cases, they seem too good to be true. Many of the SRs [systematic reviews] are of poor methodological quality, based on poor quality primary studies, published in less than reputable journals...there are more and more SRs by Chinese authors focussed on Chinese herbal mixtures that are unknown and unobtainable outside China. These SRs are invariably based on studies published in Chinese language in journals that are inaccessible. This means it is almost impossible for the reader, reviewer or editor to check their accuracy. The reliability of the conclusions of these SRs must therefore be doubted. Most of the primary studies included in the SRs lack long-term data. Thus the usefulness of the SCAM [so-called alternative medicine] in question is questionable...Several contradictions emerge from some of the SRs of the same modality. This is particularly confusing because SRs are supposed to be the most reliable type of evidence...Because of this confusion, SCAM advocates are able to select false-positive SRs to support their opinion that SCAM is effective.”

Infertility: Clark et al. 2013. Int J Gynaecol Obstet. 122(3):202-6: “Although there is preliminary evidence of the effectiveness of some CAM interventions among infertile patients, many of these interventions require further investigation before they can be considered for routine clinical use.”

Insomnia: Zhou et al. 2017. Med Clin North Am. 101(5):865-79: “There is a growing body of literature suggesting that mindfulness-based stress management, yoga, and tai chi may improve insomnia symptoms. Current data do not support routine use of dietary supplements for sleep.”

Irritable bowel syndrome:

• Grundmann and Loon 2014. World J Gastroenterol. 20(2):346-62: “Over the past decade, a number of important clinical trials have shown that specific herbal therapies (peppermint oil and Iberogast(®)), hypnotherapy, cognitive behavior therapy, acupuncture, and yoga present with improved treatment outcomes in IBS patients.”

• Nguyen et al. 2016.  Inflamm Bowel Dis. 22(6):1412-7: “CAM-IBD [CAM for irritable bowel disease], but not CAM-GEN [CAM for general health], was associated with lower adherence to IBD medical therapy.”

• Stein 2017. Gastroenterol Clin North Am. 46(4):875-80: “Complementary and alternative medicine is frequently used by inflammatory bowel disease (IBD) patients; most common are massage, acupuncture, and moxibustion therapy. Massage therapy is poorly studied in IBD patients; therefore, its benefits remain unknown. Acupuncture and moxibustion therapy have been shown to improve inflammation and symptoms in animal and human studies. However, current clinical trials of acupuncture and moxibustion are of insufficient quality to recommend them as alternative therapy.”

• Winter and Korzenik 2017. Gastroenterol Clin North Am. 46(4):907-16: “Complementary and alternative medicine (CAM) has its limitations with regard to the need for better and more robust data, particularly because most studies in CAM for inflammatory bowel disease (IBD) are small, short-term, and do not address drug interactions with IBD medications.”

• Cheifetz et al. 2017. Gastroenterology. 152(2):415-29: “CAMs of various forms are used by more than half of patients with IBD during some point in their disease course...We discuss evidence for the effects of herbs (such as cannabis and curcumin), probiotics, acupuncture, exercise, and mind-body therapy. There have been few controlled studies of these therapies, which have been limited by their small sample sizes; most studies have been uncontrolled. In addition, there has been a lack of quality control for herbal preparations.”

• Phatak et al. 2019. Pediatr Gastroenterol Nutr. 68(2):157-60: “Prevalence of CAM use ranges from 22% to 84% in children with IBD all over the world. CAM use in IBD includes diet changes, supplements, herbals, botanicals, and mind-body therapies. Common reasons for using CAM include severe disease and concern for adverse effects of conventional medicines. Despite widespread use, there are limited studies on efficacy and safety of CAM in children. Small studies suggest a favorable evidence for use of probiotics, fish oil, marijuana, and mind-body therapy in IBD. Adverse effects of CAM are reported but are rare.”

Lipid levels: Posadzki et al. 2016. Complement Ther Med. 29:141-51: “There was conflicting evidence regarding the effectiveness of garlic; and promising evidence for yoga...To conclude, the evidence from SRs evaluating the effectiveness of CAM in lowering BLL [blood lipid levels] is predominantly equivocal and confusing.”

Liver disease: Henson et al. 2017. J Clin Gastroenterol. 51(6):564-70: “Of the 647 adults with liver disease, 41% reported using CAM in the prior year, compared with 33% of adults without liver disease. The most common modality was herbs and supplements (23%), and 3% of respondents reported consumption of a potentially hepatotoxic substance in the previous 30 days. Only a small proportion of CAM therapies were used specifically for liver disease, with milk thistle being the most common... Many do not disclose their CAM use to their providers, despite some using potentially hepatotoxic substances.”

Lupus: Greco et al. 2013. Curr Rheumatol Rep. 15(11):378: “It is estimated that over 50% of patients with systemic lupus erythematosus (SLE) have utilized complementary and alternative medicine (CAM) treatments to reduce symptoms and manage their health. However, there are relatively few randomized controlled trials of CAM for SLE...The recent trials of CAM treatments for SLE indicate that supplements such as vitamin D, omega 3 fatty acids, N-acetyl cysteine and turmeric show some promise for reducing SLE disease activity. In addition, mind-body methods such as cognitive-behavioral therapy and other counseling interventions may improve mood and quality of life in SLE.”

Menopausal symptoms:

• Taylor 2015.  Endocrinol Metab Clin North Am. 44(3):619-48: “Few botanic therapies suggested for menopause have robust evidence for efficacy and safety. Pycnogenol, pollen extract, ERr731 (rhubarb extract), S-equol, and genistein may offer some symptom mitigation. Soy foods offer limited symptom relief. Red clover, evening primrose oil, Panax ginseng, Dioscorea, and vitamin E are ineffective. At best, botanicals decrease vasomotor symptoms 15% to 30% better than placebo.”

• Mintziori et al. 2015. Maturitas. 81(3):410-3: “There is insufficient or conflicting evidence to suggest that exercise, supplements or a diet rich in phytoestrogens are effective for vasomotor menopausal symptoms...Behavioral therapies and alternative medicine interventions have been tried, but the available evidence is still limited.”

Pain:

• Close et al. 2014. J Adv Nurs. 70(8):1702-16: "There is limited evidence supporting the use of general CAM for managing pregnancy-related low back and/or pelvic pain. However, the restricted availability of high-quality studies, combined with the very low evidence strength, makes it impossible to make evidence-based recommendations for practice."

• Nahin et al. 2016.  Mayo Clin Proc. 91(9):1292-306: "Based on a preponderance of positive trials vs negative trials, current evidence suggests that the following complementary approaches may help some patients manage their painful health conditions: acupuncture and yoga for back pain; acupuncture and tai chi for OA [osteoarthritis] of the knee; massage therapy for neck pain with adequate doses and for short term benefit; and relaxation techniques for severe headaches and migraine. Weaker evidence suggests that massage therapy, SM [spinal manipulation], and osteopathic manipulation might also be of some benefit to those with back pain, while relaxation approaches and tai chi might help those with fibromyalgia." Ernst (2016 Sep 5. Edzard Ernst blog) criticized this review: "the discussion of the paper totally lacks any critical thinking; there is no assessment of the quality of the trials included in this review. My last point is by far the most important. A summary of this nature that fails to take into account the numerous limitations of the primary data is, I think, as good as worthless. As I know most of the RCTs included in the analyses, I predict that the overall picture generated by this review would have changed substantially, if the risks of bias in the primary studies had been accounted for. Personally, I find it lamentable that such a potentially worthy exercise ended up employing such lousy methodology. Perhaps even more lamentable is the fact that the NIH (or one of its Centers) can descend that low; to mislead the public in this way borders on scientific misconduct and is, in my view, unethical and unacceptable." Gorski (2016 Sep 5. Science-Based Medicine blog) criticized the framing of all non-pharmacological approaches to pain as complementary and alternative medicine, "furthering the stereotype that science- and evidence-based medicine is about nothing more than drug therapy." He noted that the review is most consistent with none of the CAM approaches examined working for chronic pain.

• Wong et al. 2016. Spine J. 16(12):1598-1630: "Our review adds new evidence to the Neck Pain Task Force and suggests that mobilization, manipulation, and clinical massage are effective interventions for the management of neck pain. It also suggests that electroacupuncture, strain-counterstrain, relaxation massage, and some passive physical modalities (heat, cold, diathermy, hydrotherapy, and ultrasound) are not effective and should not be used to manage neck pain."

• Chen and Michalsen 2017. BMJ. 357:j1284: "Chronic pain is the leading indication for use of CIM [complementary and integrative medicine], and about 33% of adults and 12% of children in the US have used it in this context...Despite the increased use of acupuncture in clinical practice, research data remain inconclusive about its effectiveness in the management of chronic pain...Evidence for the effectiveness of various mind-body interventions in chronic back and neck pain is increasing rapidly...the clinical effects of herbs from Western complementary medicine seem to be modest. Some herbs and herbal mixtures from traditional Chinese and Ayurvedic medicine might be beneficial in rheumatoid arthritis, but their safety is not yet proven." However, Ernst (2017 May 9. Edzard Ernst blog) was highly critical of this article. "The full text of this article is such that I could take issue with almost every second statement in it...they omit hundreds of sources which do not support their message, which cherry-picks only evidence for the efficacy of the treatments they promote...they bypass any material that might challenge what they include. For instance, when discussing therapeutic risks, they omit the disturbing lack of post-marketing surveillance: the reason we lack information on adverse events."

• Groenewald et al. 2017. Acad Pediatr. 17(7):785-93: The 2012 National Health Survey found that 21% of children with painful conditions used CAM. "Among children with pain who used CAM, the 2 most commonly used CAM modalities were biology-based therapies (47.3%) (eg, special diets and herbal supplements) and manipulative or body-based therapies (46.3%) (eg, chiropractic and massage)."

• Lin et al. 2017. Anesth Analg. 125(6):2081-93: "Overall, weak positive evidence was found for yoga, relaxation, tai chi, massage, and manipulation. Strong evidence for acupuncture as a complementary treatment for chronic pain that has been shown to decrease the usage of opioids was found."

• Lemmon and Hampton 2018. J Fam Pract. 67(8):474;477;480;483: Practice recommendations with good-quality patient-oriented evidence: "Recommend tai chi as an exercise modality for patients with osteoarthritis. Recommend mindfulness training for patients with chronic low back pain (LBP). Recommend a trial of either acupuncture or spinal manipulation for patients with chronic LBP."

• Han et al. 2019. Pain Med. 20(1):90-102: "Our study suggests that in this large cohort of US veterans the course of chronic pain appears no better for those who received one or more courses of acupuncture, massage, or chiropractor care than those who never received such modalities during the three-year follow-up period."

• Hassan et al. 2020. Pain Med. 21(4):836-59: "There is a small but defined body of literature demonstrating positive preliminary evidence that the IM [integrative medicine] approach including CAM therapies can help in reducing opioid use." However, Ernst (2019 Dec 12. Edzard Ernst blog) wrote: "I am unimpressed by this review...Because of their design, most of the included studies do not allow any conclusions about cause and effect. The 8 RCTs [randomized controlled trials] that would allow such conclusions are mostly of poor quality. Some of the 8 RCTs are not even what the review authors claim to be [an example was given that was not a RCT]...Most of the 8 RCTs investigate whether SCAM [so-called alternative medicine] is useful for weaning opioid-dependent patients off their drug. To equate this with the question whether IM/SCAM can reduce or cease opioid use in CP [chronic pain] patients is, I think, wrong. The way to reduce opioid use in CP patients is to prescribe less opioids."

• Zimpel et al. 2020. Cochrane Database Syst Rev. CD011216: For post-caesarean pain, benefits were possibly observed for aromatherapy, electromagnetic therapy, music, and transcutaneous electric nerve stimulation (TENS). It was uncertain whether acupuncture or acupressure, massage, and reiki provided benefits. Ernst (2020 Oct 8. Edzard Ernst blog) criticized the review: "I feel that the Cochrane Collaboration does itself no favours by publishing such poor reviews. This one is both poorly conceived and badly reported. In fact, I see little reason to deal with pain after CS differently than with post-operative pain in general. Some of the modalities discussed are not truly SCAM [so-called alternative medicine]. Most of the secondary endpoints are irrelevant. The inclusion of adverse effects as a primary endpoint seems nonsensical considering that SCAM studies are notoriously bad at reporting them. Many of the allegedly positive findings rely on trial designs that cannot control for placebo effects (e.g A+B versus B); therefore they tell us nothing about the effectiveness of the therapy. Most importantly, the conclusions are not helpful. I would have simply stated that none of the SCAM modalities are supported by convincing evidence as treatments for pain control after CS.”

Palliative care: Zeng et al. 2018. J Pain Symptom Manage. 56(5):781-94: "Many studies demonstrated a short-term benefit in symptom improvement from baseline with CAM, although a significant benefit was not found between groups...CAM may provide a limited short-term benefit in patients with symptom burden." However, Ernst (2018 Aug 21. Edzard Ernst blog) noted that "within-group changes are irrelevant and should not even deserve a mention in the abstract. Thus the only finding worth reporting in the abstract is this: No significant benefit was found."

Parkinson's disease:

• Ghaffari and Kluger 2014. Curr Neurol Neurosci Rep. 14(6):451: "At least 40% of patients with Parkinson's disease (PD) use one or more forms of alternative therapy (AT) to complement standard treatments...With a few notable exceptions, none of the treatments examined were investigated rigorously enough to draw definitive conclusions about efficacy or mechanism. Tai chi, acupuncture, Mucuna pruriens, cannabinoids, and music therapy have all been proposed to work through specific mechanisms, although current evidence is insufficient to support or refute these claims, with the possible exception of Mucuna pruriens (which contains levodopa). It is likely that most ATs predominantly treat PD patients through general mechanisms, including placebo effects, stress reduction, and improved mood and sleep, and AT may provide patients with a greater locus of control regarding their illness."

• Bega et al. 2014. Curr Treat Options Neurol. 16(10):314: "Despite high rates of utilization of complementary and alternative medicine (CAM) practices, data on efficacy is generally limited, restricting physicians in providing guidance to interested patients. Exercise is now well-established as integral in the management of PD, but mind-body interventions such as Tai Chi that incorporate relaxation and mindfulness with physical activity should be routinely encouraged as well...Many PD patients also choose to try herbs, vitamins, and neutraceuticals as part of a healthy lifestyle, with the added expectation that these products may lower free radical damage and protect them against further cell death. Evidence for neuroprotection is limited, but patients can be encouraged to maintain a healthy diet rich in 'high-power,' low-inflammatory foods, while at the same time receiving education that many promising natural products have produced disappointing results in clinical trials...A number of agents discussed here that have a proposed role in the treatment of neurodegenerative diseases (and PD in particular), including cannabis, mucuna pruriens, and Chinese herbals, deserve more attention from basic science researchers and clinical investigators before they can be either safely utilized or dismissed." 

Radiation therapy side effects: Stubbe and Valero 2013. J Adv Pract Oncol. 4(4):219-31: "The CAM therapies that may alleviate some of the side effects of radiation therapy include probiotics, psyllium, exercise, melatonin, honey, acupuncture, and calendula. Therapies that require more research or have been shown to be ineffective include aloe vera, glutamine, and deglycyrrhizinated licorice."

Restless leg syndrome: Bega and Malkani 2016. Sleep Med. 17:99-105: "Up to 65% of patients with RLS regularly use alternative practices for symptom relief...Insufficient evidence exists for yoga, acupuncture, PCDs, near-infrared light therapy, CBT, valerian, or Chinese herbs, but preliminary studies on each of these suggest that high-quality randomized controlled trials may be warranted to support and verify the data presented."

GLOSSARY OF COMPLEMENTARY AND ALTERNATIVE MEDICAL CLAIMS AND PRACTICES

Acupressure: similar to acupuncture, except that finger pressure is used rather than needles. Shiatsu is a Japanese form.

Acupuncture: method from traditional Chinese medicine, in which needles are inserted at specific points in order to relieve pain and treat disease. The "theory" behind acupuncture involves balancing of the body's "life force" (qi) as it flows through channels (“meridians”). Used in pain control, nausea, addiction, other conditions. See also auriculotherapy; acupressure.

Adrenal fatigue: an invalid diagnosis, claimed to occur due to stressful conditions, and including a variety of common and nonspecific symptoms such as tiredness and trouble sleeping.  Supposedly the stressful conditions cause "overuse" of the adrenals in producing hormones. (Adrenal insufficiency is a genuine medical condition.)

Allergy treatments: abuses in this area include invalid methods of diagnosis and treatment, especially of nonexistent food allergies. See also applied kinesiology; clinical ecology; IgG testing; Nambudripad’s Allergy Elimination Technique (NAET); provocation and neutralization.

Alternative medicine: approaches generally not considered part of standard medicine. See also complementary and alternative medicine; complementary medicine; functional medicine; integrative medicine.

Alexander Technique: an approach based on correcting posture, used to treat a variety of conditions.

Anma massage (anma therapy): a type of massage in traditional Japanese medicine.

Anthroposophic medicine: a medical approach based on the teachings of Rudolf Steiner.

Antineoplastons: cancer treatment invented by Stanislaw Burzynski, using substances originally extracted from urine.

Antioxidants: certain vitamins and other chemicals protect the body from free radical damage (which can lead to disease). Exaggerated claims are made by promoters of dietary supplements. See also orthomolecular therapy; vitamins.

Apitherapy: see bee venom therapy.

Applied kinesiology: invalid diagnostic method in which muscle strength is tested while substances are placed in contact with subject's body (such as under the tongue). Used to prescribe nutritional supplements, or to detect allergies or other disorders.

Aromatherapy: use of plant oils (either massaged into the skin or inhaled) to enhance mental state or treat disease.

Arthritis treatments: questionable methods include vitamins, vibrators, special diets, chiropractic, acupuncture, alfalfa tablets, copper bracelets, DMSO, honey/vinegar mixtures, and cod liver or fish oil. Glucosamine (often combined with chondroitin sulfate) is currently popular but supportive evidence is not yet convincing. See also prolotherapy.

Auriculotherapy: similar to acupuncture, except that various portions of the body are represented by acupuncture points in the ear.

Ayurverdic medicine: traditional medicine of India. Includes diet, herbs, massages, and other therapies. Has some elements of Hindu theology. See also doshas; panchakarma.

Bach Flower Remedies: set of highly-diluted plant preparations invented by Edward Bach; used for psychological conditions.

Bee venom therapy (bee sting therapy, apitherapy, bee venom acupuncture): involves applying live bees to the body for the supposed benefits of the stings. It has been promoted for arthritis, other forms of pain, multiple sclerosis, stroke, and other conditions.

Behavioral vision therapy (behavioral optometry): use of vision exercises to improve reading, deal with learning problems, etc.

Biofeedback: patients learn to control normally involuntary physiological processes by watching monitors that display measurements of skin temperature or electrical properties. Said to allow improved circulation to the extremities. Also used for stress, pain, asthma, epilepsy, attention-deficit disorder, and other conditions.

Bioidentical hormones: estrogen and progesterone (made synthetically, but identical to human forms), given in individualized doses by compounding pharmacists.

Bodywork: various treatments involving touching, manipulating, or exercising the body. May claim to correct problems with "energy" fields.

Botanicals: products that contain plant materials, algae, and/or microscopic fungi. See also herbs.

CAM: see complementary and alternative medicine.

Cancer therapies: patients battling cancer may turn to alternative therapies. Some seek treatments in foreign countries such as Mexico. See also antineoplastons; cell therapy; colonic irrigation; Essiac; Gerson therapy; hyperoxygenation therapy; laetrile; metabolic therapy; and shark cartilage.

Candidiasis hypersensitivity (yeast syndrome): presence of the normally harmless yeast Candida albicans is alleged to be responsible (at least in part) for a wide variety of ailments, ranging from fatigue and irritability to arthritis and multiple sclerosis. Special diets, supplements, and anti-fungal drugs are recommended by alternative practitioners.

Cell therapy (live cell therapy, fresh cell therapy): injection of cells (e.g., fetal lamb cells) to "rejuvenate" the body.

Chelation therapy: chemicals such as ethylenediamine tetraacetic acid (EDTA), which bind calcium and other metals, are injected into the blood stream. Said to reverse atherosclerosis and to treat illness due to "free radical pathology." Used for heart disease and many other conditions.

Chi: see qi.

Chiropractic: a method of treatment based on the premise that misalignments of the spine ("subluxations") produce a variety of ailments, which can be treated by spinal manipulations. The most popular of alternative practices, with about 70,000 chiropractors in the United States. They are nearly fully integrated into the health care system, being licensed in all states and covered by most health insurance plans. Most frequently consulted for back problems, but many chiropractors claim to be able to treat or prevent other medical problems, and wish to be considered as primary care providers. See also naprapathy; subluxation.

Clinical ecology (environmental illness, multiple chemical sensitivity): practice that diagnoses allergies to multiple chemicals or factors in patient's environment . Many patients may have psychosomatic diseases.

Chromotherapy: see color healing.

"Chronic Lyme disease": while Lyme disease is a genuine disorder, some alternative practitioners ("Lyme literate physicians") diagnose the disease in the absence of usual signs of Lyme, using nonstandard tests, and treat using unconventional therapies.

Clinical ecology: specialty that deals with alleged sensitivity to multiple common foods and chemicals (multiple chemical sensitivity).

Coffee enemas: see colonic irrigation.

Cold laser: see low level laser therapy

Colonic irrigation: a treatment to remove "toxins" alleged to produce health problems. Large amounts of water are pumped into the colon. Sometimes other substances (such as coffee) are added. Employed in some alternative cancer therapies. See also detoxification.

Color healing (chromotherapy): treatment based on the idea that different colors have different effects on the body. May employ colored light or other methods.

Complementary and alternative medicine (CAM): general term used to encompass unconventional medical approaches, whether used along with or instead of standard methods.

Complementary medicine: use of unconventional approaches along with (to complement) standard medicine, in contrast to being used instead of standard treatments.

Craniosacral therapy: an approach based on manipulating the bones of the cranium (which actually do not move) to influence the rhythm (which does not exist) in cerebrospinal fluid.

Crystal healing: "energy" produced by crystals allegedly causes healing, relieves stress, tunes body's "vibrations," etc.

Cupping: method from traditional Chinese medicine in which cups are placed on the body, and low pressure then created within the cup, drawing blood to the area.

Detoxification ("detox"): it is claimed that various unspecified "toxins" accumulate in the body and must be removed by methods such as colonic irrigation or dietary supplements.

Dietary supplements: edible substances that allegedly provide health benefits, but which are not regulated as strictly as drugs.  Examples include vitamins in large doses (megadoses), herbs, antioxidants, minerals, and many biochemicals and other natural products. See also antioxidants; DSHEA; functional foods; "glandulars"; health claims; herbs; natural foods; nutraceuticals; organic foods; phytochemicals; structure and function claims; vitamins.

Diets: many are based on dubious claims concerning nutrition and metabolism, and some may be harmful. Currently, low carbohydrate (e.g., Atkins) and ketogenic diets are popular, with some supporting evidence, but long-term effectiveness unknown.

Distant healing: a form of "energy medicine," in which practitioners claim to be able to heal patients from a distance.

Doshas: in Ayurvedic medicine, three "humors" or principles (pitta, kapha, and vata) that influence physiological processes.

Dry needling: insertion of needles into myofascial trigger points to treat pain and muscle problems.

DSHEA (Dietary Supplement Health and Education Act): 1994 act regulating dietary supplements in the United States. The act made it easy for marketers of supplements to sell their products without demonstrating safety and effectiveness.

Ear acupuncture: see auriculotherapy.

Earthing (grounding): based on the premise that the flow of electrons from the Earth through the body neutralizes free radicals and provides health benefits.

Electroacupuncture: electrical stimulation is applied through needles inserted at acupuncture points.

Energy medicine: a collection of therapies that supposedly manipulate some type of “life energy,” unknown to science, for health benefits. Sometimes the alleged energy is referred to as “subtle energy,” and it may be thought to project beyond the body (“human energy field”). See also bodywork; distant healing; healing touch; Johrei; qi gong; reiki; therapeutic touch.

Essiac: herbal remedy promoted for cancer and other conditions.

Eye Movement Desensitization and Reprocessing (EMDR): psychotherapeutic method involving eye movements while recalling traumatic memories.

Facilitated communication: method in which nonverbal person allegedly spells out words with the assistance of a facilitator.

Full body scans: CT and MRI scans are offered to detect diseases in early stages.  However, there is not evidence that the benefits outweigh the risks of surgery or further testing to deal with detected abnormalities that may be benign.

Functional foods: foods enriched in one or more allegedly beneficial compounds. A marketing term with no legal status.

Functional medicine: an approach that claims to look at the biochemical individuality of the patient and correct the underlying causes of disease. Usually includes a large amount of testing. May provide unscientific treatments.

Gerson therapy: unorthodox cancer therapy developed by Max Gerson in the 1940's. Method emphasizes detoxification through special diets and coffee enemas. See also colonic irrigation; metabolic therapy.

"Glandulars": dietary supplements consisting of animal glands or organ tissues. The rationale is that eating this material can strengthen the corresponding human organ.

Grounding: see earthing.

Gua sha: method from traditional Chinese medicine in which a tool is used to scrape the skin.

Hair analysis: diagnostic method in which hair is analyzed for nutritional deficiencies or presence of toxic metals.

Halotherapy: sitting in a salt cave to relieve allergies and other problems.

Healing touch: similar to Therapeutic Touch. The practitioner may use light touch or hand movements close to the body to correct the patient’s “energy field.”

Health claims: in connection with dietary supplements, claims related to prevention or treatment of diseases. In the U.S., these must be approved by the Food and Drug Administration. See also structure and function claims.

Herbs: seed-producing plants without woody tissues that die at the end of the growing season. Herbs and botanicals are taken for health benefits, but are not normally consumed as food (except as flavorings). Proponents sometimes claim that their natural ingredients are better than synthetic counterparts, and that the complex mixtures give fewer side effects than purified components. See also botanicals.

HGH (human growth hormone): injected as an anti-aging remedy. Supplements that allegedly stimulate release of HGH are also marketed.

Holistic medicine: by definition, an approach which considers the whole person (including psychological and emotional needs, family situation, etc.) in planning treatment. As such, this is a proper part of conventional medical treatment. In practice, the term is used by many alternative practitioners to include unconventional methods of diagnosis and treatment.

Homeopathy: employs extremely dilute solutions of agents supposedly causing symptoms similar to disease, in order to provoke the body's natural defense mechanisms. In practice the dilutions are so high as to contain few or no molecules of the original compounds. Developed by Hahnemann around 1800; became an important part of American health care in the late 1800's before declining. See also: isopathy; miasm; proving; succussion.

Hyperbaric oxygen therapy (HBOT): delivery of oxygen at high pressure. Used in some legitimate medical treatments, but also by alternative practitioners for other conditions where evidence of effectiveness is lacking.

Hyperoxygenation therapy: see oxygenating therapies

Hypnosis: patient is placed in a state of relaxation and enhanced suggestibility. Used to treat addictive and other behavioral problems, recover lost memories, etc. See also past-life therapy.

Hypoglycemia: low blood glucose. Misdiagnosed by some alternative practitioners, who blame it for a variety of ailments and treat it with dubious remedies.

IgG testing: an invalid method of testing for food allergies.

Infrared imaging: see thermography.

Integrative medicine: the combination of conventional and unconventional ("complementary") medical treatments.

Intravenous (IV) nutrient (or micronutrient) therapy (IV drips, hydration therapy): infusions of water, vitamins, and minerals marketed to healthy individuals for the purpose of recovery from stress, detoxification, extra energy, boosted immunity, or weight loss. Also used to treat various diseases.

Iridology: an invalid diagnostic method in which examination of the iris is used to identify conditions of various organs.

Isopathy: variant of homeopathy in which dilutions of the actual causative agent are employed, rather than materials producing similar symptoms. Remedies based on inactivated microorganisms or derived from infected tissue are called nosodes.

Johrei: a Japanese form of spiritual healing involving light massage and manipulation of the body's "energy."

Kampo: a Japanese traditional herbal medicine system.

Kinesio Taping: special tape is applied directly over and around muscles. It supposedly improves lymph flow and provides numerous benefits related to pain and sports injuries.

Laetrile: trade name for amygdalin, a chemical derived from apricot pits. Sometimes referred to as "vitamin B17." Used in alternative cancer treatments. See also metabolic therapy.

Leaky gut syndrome: a supposed disorder involving defective tight junctions in the intestine.

Live cell analysis: invalid diagnostic method in which a blood sample is analyzed by dark-field microscopy (often projected on a screen), and the appearance of the cells used to assess health.

Lotus birth: the umbilical cord is left in place until it falls off naturally after a few days.

Low level laser therapy (cold laser, soft laser, low power laser, low intensity laser, monochromatic infrared light energy (MIRE) therapy): lasers with wavelengths of 600 to 1000 nm and power of 5 to 500 milliwatts are used to treat various types of pain and for wound healing.

Lyme disease: see "Chronic Lyme disease"

Magnets: static magnets are applied at various parts of the body, usually for control of pain. However, effects are too weak to bring about any physiological effects.

Mercury amalgam poisoning: chewing has been alleged to release toxic doses of mercury from mercury-amalgam dental fillings. Antiamalgamists advocate removal of all such fillings and replacement with composite resin fillings. Some use mercury-vapor analyzers to convince patients that their fillings are releasing toxic quantities of mercury.

Meridians: in traditional Chinese medicine, pathways for the flow of qi.

Metabolic therapy: treatment consisting of such components as vitamins, laetrile, other dietary supplements, and coffee enemas. Rationale is to eliminate "toxins" and enhance body's ability to heal itself. Frequently used in alternative cancer therapies.

Miasm: in homeopathy, an underlying predisposition to disease.

Mind-body medicine: field dealing with the influence of mental states on the course of a disease, or susceptibility to disease. While some claims may be exaggerated, the concepts are supported by various scientific studies, and are being applied in some mainstream medical centers. See also biofeedback; Eye Movement Desensitization and Reprocessing (EMDR); hypnosis; mindfulness; Neuro Emotional Technique (NET); Neuro-linguistic programming (NLP); placebo effect;  psychoneuroimmunology; Thought Field Therapy (TFT).

Mindfulness: a type of meditation in which there is increased awareness and acceptance of the present.

Morgellon's: a condition in which individuals have skin sores that they believe contain fibers. Considered a form of delusional parasitosis.

Moxibustion: method of traditional Chinese medicine in which heat from burning herbal material is applied at acupuncture points.

Multilevel marketing: method used by many distributors of dietary supplements and other products. Individuals are recruited to market the products to friends and neighbors; they can share more of the profit by recruiting additional people to work under them.

Multiple chemical sensitivity: see clinical ecology.

Nambudripad’s Allergy Elimination Technique (NAET): “NAET is a bizarre system of diagnosis and treatment based on the notion that allergies are caused by ‘energy blockage’ that can be diagnosed with muscle-testing and permanently cured with acupressure and/or acupuncture treatments” (Barrett 2017. Chirobase).

Naprapathy: an offshoot of chiropractic, focusing on manipulation of connective tissue.

Natural foods: foods lacking preservatives or other additives, and having minimal processing. See also "organic" foods.

Naturopathy: treatment based on the idea that disease results from the body attempting to purify itself, and can be counteracted through "natural" treatments such as special diets, food supplements, manipulations, etc. May include acupuncture, colonic irrigation, and homeopathy. Some states grant licenses to naturopaths.

Neural therapy: injection of procaine (a local anesthetic) or other substances into various body tissues.  It is based on the notion that trauma can produce long-standing disturbances in the electrochemical function of tissues.

Neuro Emotional Technique (NET): based on releasing emotional blocks which produce adverse health effects. Involves applied kinesiology, chiropractic adjustments, and other invalid methods in diagnosing and dealing with these blockages.

Neuro-linguistic Programming (NLP): “a pseudoscientific approach to communication, personal development and psychotherapy...NLP asserts that there is a connection between neurological processes (neuro-), language (linguistic) and acquired behavioral patterns (programming), and that these can be changed to achieve specific goals in life” (Wikipedia 2023. Neuro-linguistic Programming).

"New Age" approaches: variety of techniques related to supposed ancient esoteric wisdom, higher states of consciousness, etc. See also color healing; crystal therapy; energy medicine; reiki.

Nosodes: see isopathy.

Nutraceuticals: dietary supplements delivering compounds derived from foods in concentrated form.

"Organic" food: food grown without the use of artificial fertilizers or pesticides. See also natural foods.

Orthomolecular therapy: use of megadoses of vitamins, and other normal body constituents, in treatment. Term invented by Linus Pauling.

Osteopathy: a system which emphasizes the relationship of the muscles and skeletal system to organ function. It employs manipulation as well as other treatments. In contrast to chiropractic, it has adopted many concepts and practices of conventional medicine. Doctors of osteopathy receive training similar to doctors of medicine; are licensed in all states; and have the same rights and responsibilities as M.D.'s in nearly all states.

Oxygenating therapies: various methods attempt to provide oxygen or oxygenating compounds to the body.  This supposedly aids in metabolism (giving more "energy"), provides oxygen to cells and tissues that may not be well oxygenated, fights cancer and HIV, helps weight loss, and assists in numerous other conditions. See also hyperbaric oxygen therapy.

Panchakarma: in Ayurvedic medicine, a set of procedures to detoxify the body.

Past-life therapy: patients are regressed under hypnosis to "remember" events in past lives; these are thought to underlie psychological disorders.

Phytochemicals: plant chemicals that are claimed to have beneficial effects on health.

Placebo effect: psychological effect of a fake treatment not containing the active principle.

Prolotherapy: injection of an irritant to treat pain from arthritis or other conditions.

Proving: in homeopathy, testing a remedy on a healthy person and observation of symptoms; this then guides the therapeutic use.

Provocation and neutralization: an invalid method of diagnosing and treating food allergies. A food extract is injected in the arm or placed under the tongue, and symptoms such as drowsiness or fatigue are looked for.  A weaker neutralizing dose is then used to treat the disorder.

Provoked challenge urine testing: an invalid diagnostic method in which a chelating agent is administered, followed by a urine test for toxic heavy metals. The artificially high levels of the metals are then used as a justification for detoxification treatment.

Pulse diagnosis: in traditional Chinese medicine, it is thought that there are many pulses, each with numerous qualities that can be used in diagnosis. Also used in Ayurvedic medicine.

Psychic surgery: method in which the practitioner purports to create an incision with the fingers, remove a tumor or other body part, and close the wound (leaving no scar). Has been exposed as sleight-of-hand trickery. Usually includes appeals to the religious faith of the "patient." While some psychic surgeons practice in the United States, the most popular are in foreign countries.

Psychoneuroimmunology: the study of relationships between the brain and the immune system. Part of mind-body medicine.

Qi (Chi): concept from traditional Chinese medicine, related to life energy. Approaches aim to balance the distribution of qi in the body. See also acupuncture, qi gong; meridian; tai chi; traditional Chinese medicine.

Qi gong: part of traditional Chinese medicine. Internal qi gong involves deep breathing exercises for health and relaxation. In external qi gong, a "master" performs exercises around the subject without making any physical contact, allegedly balancing vital energy (qi) to cure or prevent disease.

Reflexology: manipulation of the feet (or hands) to relieve pain or treat disease. Specific portions of the feet are claimed to correspond to different portions of the body.

Reiki: a technique with Asian roots, in which a practitioner uses hand motions to balance the body's "aura." A form of energy medicine.

Rolfing: therapy based on ideas of Ida Rolf. Involves pressure on the fascia to treat various problems.

Shark cartilage: marketed as an anti-cancer therapy, based on content of a factor inhibitory to angiogenesis (growth of new blood vessels).

Shiatsu: see acupressure.

Siddha: a traditional medical system of southern India.

Spot reduction: approaches to remove fat from specific portions of the body through creams, vibrators, exercises, etc.

Stem cells: cells capable of differentiating into other cell types. An important area of research and therapy within conventional medicine. However, some practitioners are promoting treatments for which safety and effectiveness have not been demonstrated.

Structure and function claims: in the United States under DSHEA, promoters of dietary supplements are allowed to make vague claims about bodily structures and functions as long as they do not refer to prevention or treatment of specific diseases. Claims supposedly have scientific support but do not need to be approved by the Food and Drug Administration. See also health claims.

Subluxation: as used by chiropractors, a slight misalignment of the spine that leads to medical problems. Chiropractic adjustments aim to correct them.  (Note: subluxation is also a medical term, but the medical usage refers to a much more severe abnormality than in the usage given by chiropractors.) See also chiropractic.

Succussion: in the preparation of a homeopathic remedy, the vigorous shaking applied after a dilution.

Tai chi: system of exercises involving slow, gentle movements.

Testosterone supplementation: recommended by some practitioners to offset the decrease in testosterone which occurs normally in men with aging.

Therapeutic touch: treatment of illness by using the hands to adjust the "energy state" of the patient; allegedly can occur without any physical contact. Promoted among nurses. Healing touch is similar.

Thermogenic supplements (fat burners) - claimed to increase body's metabolism and consume calories apart from the need to do muscular work.

Thermography (infrared imaging): uses heat from the body in imaging. Has been promoted for breast cancer screening and also by chiropractors.

Thought Field Therapy (TFT): - psychological problems are alleged to involve disturbances in “energy fields” (or “thought fields”) in the body. These are supposedly corrected through sequences of tapping on various acupressure points, plus other sensory activities.

Tongue diagnosis: in traditional Chinese medicine, examination of the tongue is used to diagnose many conditions.

Traditional Chinese medicine (TCM): a complex system of diagnosis and treatment based on prescientific understanding of the human body. Attempts to maintain wellness by balancing yin and yang forces and the distribution of qi energy in the body. See also acupressure; acupuncture; auriculotherapy; cupping; electroacupuncture; gua sha; meridian; moxibustion; pulse diagnosis; qi; qi gong; tai chi; tongue diagnosis; tui na.

Tui na: a type of massage treatment in traditional Chinese medicine.

Unani: a traditional medicine system of central Asia and India. It has Greek, Arabic, and Persian roots.

Vibratory therapy: see whole-body vibration.

Vitalism: doctrine that there is a distinct principle governing living things, not explainable by ordinary chemistry and physics.

Vitamin C: large doses have been promoted as a treatment for cancer and the common cold.

Vitamins: marketers of dietary supplements promote consumption of large doses of vitamins, but such doses often are regarded as unnecessary or even harmful by the medical community. Products not recognized as vitamins (e.g., "vitamin B15") have also been marketed. See also antioxidants; orthomolecular therapy; vitamin C.

Whole body scans: see full body scans.

Whole-body vibration (vibratory therapy): a vibrating platform produces rapid muscle contractions. Promoted for weight loss, treatment of osteoporosis, and other benefits.

Yeast syndrome: see Candidiasis hypersensitivity.

Yoga: an Indian traditional system of exercise and philosophy, thought to provide numerous health benefits.

REFERENCES

Complementary and alternative medicine: general aspects

Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins DR, Delbanco TL. 1993. Unconventional medicine in the United States. Prevalence, costs, and patterns of use. N Engl J Med. 328(4):246-52 (see critique, next item)

Gorski T. 2002. The Eisenberg data: flawed and deceptive. Quackwatch [critique of 1993 study]

Eisenberg DM, Davis RB, Ettner SL, Appel S, Wilkey S et al. 1998. Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey. JAMA. 280(18):1569-75

Raso J. 1997. Metaphysical dictionary contents. Quackwatch [describes 1200 terms related to alternative methods]

Sampson WI. 1998. The braid of the "alternative medicine" movement. Quackwatch

Astin JA. 1998. Why patients use alternative medicine: results of a national study. JAMA. 279(19):1548-53

United States Senate Special Committee on Aging 2001 Sep 10. Hearing on swindlers, hucksters and snake oil salesmen: the hype and hope of marketing anti-aging products to seniors.

• Testimony of Robert Baratz. Quackwatch

• Testimony of Timothy Gorski. Quackwatch

[critiques of trends in alternative medicine and dietary supplements]

Barrett S. 2004. Miniglossary of "alternative" methods. Quackwatch

Bellamy J. 2014 Aug 21. Tens of millions for CAM research - and it’s all on your dime. Science-Based Medicine

Hall H. 2015. Science based medicine. JamesRandiFoundation [set of videos, including several topics in complementary and alternative medicine]

Clarke TC, Black LI, Stussman BJ, Barnes PM, Nahin RL. 2015. Trends in the use of complementary health approaches among adults: United States, 2002-2012. Natl Health Stat Report. (79):1-16

Widder RM, Anderson DC. 2015. The appeal of medical quackery: a rhetorical analysis. Res Social Adm Pharm. 11(2):288-96 [abstract]

National Center for Complementary and Integrative Health. 2016. Paying for complementary and integrative health approaches

Bellamy J. 2016 Feb 18. Health savings accounts: a tax-sheltered way to pay for quackery. Science-Based Medicine

Jou J, Johnson PJ. 2016. Nondisclosure of complementary and alternative medicine use to primary care physicians: findings from the 2012 National Health Interview Survey. JAMA Intern Med. 176(4):545-6

Whedon J, Tosteson TD, Kizhakkeveettil A, Kimura MN. 2017. Insurance reimbursement for complementary healthcare services. J Altern Complement Med. 23(4):264-7 [abstract]

Bellamy J. 2017 Mar 16. Health savings accounts and quackery revisited. Science-Based Medicine

Ernst E. 2017 Jun 6. The "other medicine"...how shall we call it? Edzard Ernst

Gavura S. 2017 Oct. 19. Australia ends insurance subsidies for naturopathy, homeopathy, and more. Science-Based Medicine

Gorski D. 2018 Jan 3. The next frontier in “integrative medicine”: getting Medicaid to fund quackery. Respectful Insolence

Gavura S. 2018 Jun 14. So-Called Alternative Medicine. Science-Based Medicine [review of Edzard Ernst's book SCAM]

Mozes A. 2018 Oct 23. Is crowdfunding too often used for bogus treatments? HealthDay [see next item]

Vox F, Folkers KM, Turi A, Caplan AL. 2018. Medical crowdfunding for scientifically unsupported or potentially dangerous treatments. JAMA. 320(16):1705-6

Black LI, Barnes PM, Clarke TC, Stussman BJ, Nahin RL. 2018. Use of yoga, meditation, and chiropractors among U.S. children aged 4-17 years. NCHS Data Brief. (324):1-8  [abstract with link to pdf file]

Clarke TC, Barnes PM, Black LI, Stussman BJ, Nahin RL. 2018. Use of yoga, meditation, and chiropractors among U.S. adults aged 18 and over. NCHS Data Brief. (325):1-8  [abstract with link to pdf file]

Ernst E. 2019 Feb 25. SCAM [so-called alternative medicine] for animals. Part 2. Edzard Ernst

Gorski D. 2019 Sep 2. Veterinary quackery at the San Diego Zoo. Science-Based Medicine

Hall H. 2019 Sep 17. Professor gives grades to alternative medicine. Science-Based Medicine [review of Edzard Ernst's book Alternative Medicine: A Critical Assessment of 150 Modalities]

Ernst E. 2019 Nov 29. An ethicist, feminist view on so-called alternative medicine (SCAM). Edzard Ernst

Gorski D. 2019 Dec 16. NCCIH surveys physicians on their recommendation of “complementary health approaches,” with depressing results. Science-Based Medicine

Hall H. 2020 May 19. Don't Believe What You Think. Science-Based Medicine [review of, and excerpts from, Edzard Ernst's book]

Ernst E. 2020 Oct 19. Manifesto against pseudosciences in health. Edzard Ernst

Tangkiatkumjai M, Boardman H, Walker DM. 2020. Potential factors that influence usage of complementary and alternative medicine worldwide: a systematic review. BMC Complement Med Ther. 20(1):363

Ernst E. 2020 Dec 19. Factors that influence usage of so-called alternative medicine. Edzard Ernst [see previous item]

Ernst E. 2021 Feb 10. Current research activity in various areas of so-called alternative medicine. Edzard Ernst

Ernst E. 2021 Feb 23. What is the best umbrella term for an area of healthcare comprising modalities as diverse as homeopathy, acupuncture, iridology, dietary supplements and about 400 more? Edzard Ernst

Bellamy J. 2021 Jul 2. Sen. Rubio's proposed tax shelters for quackery. Science-Based Medicine

Barrett S. 2022. Be wary of "alternative," "complementary,” and “integrative” health methods. Quackwatch

Ernst E. 2022 Apr 6. The new "WHO Global Centre for Traditional Medicine" in India. Edzard Ernst

Scott R, Nahin RL, Sussman BJ, Feinberg T. 2022. Physician office visits that included complementary health approaches in U.S. adults: 2005-2015. J Integr Complement Med. 28(8):641-50

Stussman BJ, Nahin RL, Barnes PM, Scott R, Feinberg T, Ward BW. 2022. Reasons office-based physicians in the United States recommend common complementary health approaches to patients: an exploratory study using a national survey. J Integr Complement Med. 28(8):651-63 [abstract]

Ernst E. 2022 May 25. US Physician office visits that included complementary health approaches. Edzard Ernst

Ernst E. 2022 Aug 23. The prevalence of SCAM [so-called alternative medicine] use in general populations: No, it’s NOT increasing. Edzard Ernst

Hall 2022 Nov 15. Medicare and alternative medicine. Science-Based Medicine

Ernst E. 2023 Mar 20. The "little extras" that make ineffective treatments appear to be effective. Edzard Ernst

Ernst E. 2023 Mar 28. Research activity in so-called alternative medicine (SCAM), 2020-2022. Edzard Ernst

Ijaz N, Carrie H. 2023. Governing therapeutic pluralism: An environmental scan of the statutory regulation and government reimbursement of traditional and complementary medicine practitioners in the United States. PLOS Glob Public Health. 3(8):e0001996

“Right to try” laws

Bellamy J. 2014 Mar 6. The illusions of "right to try" laws. Science-Based Medicine

Gorski D. 2014 Mar 6. Dallas Buyers Club-inspired “right to try” laws: good movies don’t make good policy. Respectful Insolence

Gorski D. 2016 Sep 30. A victory and a more substantial defeat for the cruel sham known as “right to try.” Respectful Insolence

Gorski D. 2017 Aug 5. The cruel sham of “right-to-try” takes a giant step towards becoming federal law. Science-Based Medicine

Gorski D. 2017 Aug 30. “Right To Choose Medicine”: The free market fundamentalist assault on the FDA continues. Respectful Insolence

Gorski D. 2018 Jan 15. The final push to pass a federal version of the cruel sham of “right-to-try” is under way. Science-Based Medicine

Gorski D. 2018 May 21. The very worst version of the sham known as “right-to-try” is poised to become law. Science-Based Medicine

Gorski D. 2018 Jun 4. Right-to-try is now law. Let patients beware! Science-Based Medicine

Gorski D. 2018 Jun 11. Some final thoughts (for now) on right-to-try, the Stanislaw Burzynski of drug regulation laws. Respectful Insolence

Feuerstein A. 2018 Jun 20. Here come the right-to-try profiteers. The FDA is powerless to stop them. STAT

Gorski D. 2018 Jun 22. As I predicted, the exploitation of desperate patients using right-to-try begins. Respectful Insolence

Bellamy J. 2019 Jan 17. “Right to try” laws create tremendous legal uncertainties; FDA expanded access preferable. Science-Based Medicine

National Center for Complementary and Integrative Health and its predecessors

NCCIH web site

Atwood KC. 2003. The ongoing problem with the National Center for Complementary and Alternative Medicine. Skeptical Inquirer. 27(5): 23-2

Gorski D. 2013 Aug 21. The director of NCCAM wants a "nuanced conversation" about "complementary and alternative medicine." Respectful Insolence

Mielczarek EV, Engler BD. 2014. Selling pseudoscience: a rent in the fabric of American medicine. Skeptical Inquirer. 38(3):44-51

Gorski D. 2014 Dec 18. Congress polishes the turd that was NCCAM. Respectful Insolence

Krainin T. 2015 Sep 4. The alternative medicine racket: how the feds fund quacks. Reason [article plus 15 min video]

Engler BD, Mielczarek EV. 2015. Encouraging evidence-free enterprise: business on a bed of sand. Skeptical Inquirer. 39(5):47-51 [small business grants from NCCAM]

Ernst E. 2016 Dec 14.The mainstreaming of quackery: the role of the "NCCIH." Edzard Ernst

Gorski D. 2016 Jan 7. NCCIH research: Nothing much there behind the curtain. Respectful Insolence

Gorski D. 2016 Mar 27. Along with the NIH budget hike comes a less welcome large hike in the budget for quackery for the NCCIH. Respectful Insolence

Gorski D. 2016 Apr 4. NCCIH Strategic Plan 2016-2021, or: let’s try to do some real science for a change. Science-Based Medicine

Gorski D. 2018 Aug 31. Helene Langevin is named NCCIH director. Let the quackery flow again! Respectful Insolence

Rawlins R. 2019 Jan 8. A review of “A New Year’s Message” from NCCIH’s Director: Helene Langevin M.D. Edzard Ernst

Gorski D. 2021 Jun 28. NCCIH Strategic Plan 2021–2025: Meet the new plan, same as the old plan…? Science-Based Medicine

Common themes in complementary and alternative medicine

Ernst E. 2014 May 16. A conspiracy theory seems to be driving the popularity of alternative medicine. Edzard Ernst

Hall H. 2014. Defending science-based medicine: 44 doctor-bashing arguments …and their rebuttals. Skeptical Inquirer. 38(6):32-7

Gorski D. 2016 May 9. Are medical errors really the third most common cause of death in the U.S.? Science-Based Medicine [see also 2019 Feb 4 item below]

Gorski D. 2017 Mar 20. The Galileo Gambit: just because your quackery is rejected by the establishment does not make you Galileo or Semmelweis. Respectful Insolence

Hall H. 2017 Oct 24. Mainstream doctors actually do what CAM claims they don't. Science-Based Medicine

Ernst E. 2017 Dec 29. Alternative medicine and disease prevention…repeating an untruth does not make it a truth. Edzard Ernst

Ernst E. 2018 Dec 1. The common assumptions of alternative medicine are unmitigated nonsense. Edzard Ernst

Gorski D. 2019 Feb 4. Are medical errors really the third most common cause of death in the U.S.? (2019 edition). Science-Based Medicine

Ernst E. 2020. Fallacies of esoteric medicine. Wien Klin Wochenschr. 132(9-10):224-7

Gorski D. 2020 Feb 3. Are medical errors really the third most common cause of death in the U.S.? (2020 edition). Science-Based Medicine [see next item]

Rodwin BA, Bilan VP, Merchant NB, Steffens CG, Grimshaw AA et al. 2020. Rate of preventable mortality in hospitalized patients: a systematic review and meta-analysis. J Gen Intern Med. 35(7):2099-2106

Hall H. 2020. How you can really boost your immune system. Skeptical Inquirer. 44(4):17-9

Novella S. 2021 Aug 11. Buzzword medicine - anti-proinflammatory. Science-Based Medicine

Gorski D. 2021 Aug 13. A bogus statistic about medical errors rears its ugly head in STAT. Respectful Insolence

Ernst E. 2021 Oct 7. Treating the ROOT CAUSES of disease? The wishful thinking of SCAM practitioners and their advocates. Edzard Ernst

Tiller N. 2022 May 26. Ten health and wellness buzzwords every skeptic should know. Skeptical Inquirer

Ernst E. 2022 Oct 13. "Arguments" used to defend so-called alternative medicine. Edzard Ernst

Complementary and alternative medicine - scientific critique

Crislip M. 2014 May 16. More dialogs. Science-Based Medicine

Ernst E. 2015 Jul 30. Some alternative medicine journals should be de-listed. Edzard Ernst

Ernst E. 2017 Jun 5. Are alternative practitioners fear-mongers? Edzard Ernst

Holden G, Barker K. 2018. Should social workers be engaged in these practices? J Evid Inf Soc Work. 15(1):1-13 [lists 418 questionable practices]

Hall H. 2018 Jan 16. The elephant in the compounding pharmacy. Science-Based Medicine

Novella S. 2018 Jan 17. Infiltrative pseudoscience. Science-Based Medicine

Novella S. 2018 Sep 12. A culture of standards matters. Science-Based Medicine

Shahvisi A. 2019. Medicine is patriarchal, but alternative medicine is not the answer. J Bioeth Inq. 16(1):99-112

Ernst E. 2019 May 28. So-called alternative medicine (SCAM) causes harm in multiple ways - here are 10 dangers that come to my mind. Do you know more? Edzard Ernst

Snyder J, Cohen IG. 2019. Medical crowdfunding for unproven medical treatments: should Gofundme become a gatekeeper? Hastings Cent Rep. 49(6):32-38 [abstract]

Gorski D. 2019 Dec 30. How do we stop crowdfunding sites like GoFundMe from being used to fund quackery? Science-Based Medicine [see previous item]

Ernst E. 2020 Apr 29. 13 Characteristics of bogus so-called alternative medicines (SCAMs). Edzard Ernst

Ernst E. 2022 Jan 7. 10 SCAM “discoveries” that did not change the world. Edzard Ernst

Tiller N. 2022 Sep 23. Ten health and wellness fallacies every skeptic should know. Skeptical Inquirer

Nan X, Wang Y, Thier K. 2022. Why do people believe health misinformation and who is at risk? A systematic review of individual differences in susceptibility to health misinformation. Soc Sci Med. 314:115398 [abstract]

Ernst E. 2022 Dec 29. So-called alternative medicine (SCAM) for animals is not evidence-based and borders on animal abuse. Edzard Ernst

Jarry J. 2023 Apr 28. The World Health Organization has a pseudoscience problem. McGill Office for Science and Society

Tiller NB, Sullivan JP, Ekkekakis P. 2023. Baseless claims and pseudoscience in health and wellness: a call to action for the sports, exercise, and nutrition-science community. Sports Med. 53(1):1-5 [abstract]

Ernst E. 2023 Jan 21. My concerns about the current research activity in so-called alternative medicine (SCAM). Edzard Ernst

Adverse effects

Polevoy T. 2018. Complementary medicine: risks to infants and children. J Clin Med. 7(6):149

Gavura S. 2021 Jun 24. The risks associated with alternative medicine. Science-Based Medicine

Integrative medicine (see also Medical schools and healthcare systems; Complementary and alternative methods for specific areas of medicine (section on pain))

Marcus DM, McCullough L. 2009. An evaluation of the evidence in "evidence-based" integrative medicine programs. Acad Med. 84(9):1229-34

Bellamy J. 2016 Apr 14. Academic Consortium plan: force medical residents to practice integrative medicine. Science-Based Medicine

Gorski D. 2016 May 15. "Integrative" medicine versus "alternative" medicine. Science-Based Medicine

Luke J. 2016 Jun 12. The harm of integrative medicine: a patient's perspective. Science-Based Medicine

Gorski D. 2016 Jul 18. “Complementary and Integrative Health” at the VA: Integrating pseudoscience into the care of veterans. Science-Based Medicine

Gorski D. 2016 Jul 27. The "big idea" behind integrative medicine is not so big at all... Respectful Insolence

Jones C. 2016 Aug 12. Dana Farber Cancer Center's integrative medicine expansion. Science-Based Medicine

Gorski D. 2016 Sep 21. Quackademic medicine marches on, Stanford edition. Respectful Insolence

Gorski D. 2016 Nov 21. Milestones on the path to integrating quackery with medicine. Science-Based Medicine

Bellamy J. 2016 Dec 8. State Medical Boards should not recognize board certification in “Integrative Medicine.” Science-Based Medicine

Gorski D. 2017 Jan 8. Myths integrative medicine sells us: “We never advocate alternative medicine without conventional medicine.” Science-Based Medicine

Gorski D. 2017 Jun5. The closure of major integrative medicine “Crown Jewels”: Terminating the Terminator? Science-Based Medicine

Novella S. 2017 Sep 20. Quackademic medicine at UC Irvine. Science-Based Medicine

Hiltzik M. 2017 Sep 25. Facing criticism, UC Irvine scrubs "homeopathy" from its roster of offered treatments. Los Angeles Times [Susan Samueli Integrative Health Institute]

Novella S. 2017 Oct 4. More integrative propaganda. Science-Based Medicine

Gorski D. 2017 Oct 11. On the "integration" of quackery into the medical school curriculum. Respectful Insolence

Jones C. 2017 Oct 20. The American Academy of Pediatrics has an integrative medicine problem. Science-Based Medicine

Gorski D. 2017 Oct 23. UC-Irvine, integrative medicine, and the delusion of being "science-based." Science-Based Medicine

Mole B. 2017 Nov 27. Creeping quackery: “Integrative” cancer care spreading in NIH-supported centers. Ars Technica

Gorski D. 2018 Jan 16. Integrative medicine as infiltrative pseudoscience: Pushback against quackery. Respectful Insolence

Gorski D. 2018 Jan 18. Credulous promotion of “integrating” quackery into medicine. Respectful Insolence

Gorski D. 2018 Apr 9. Another pebble in the quackademic integrative avalanche. Science-Based Medicine

Dinerstein C. 2018 May 11. Integrative medicine's war on pain and science comes to the hospital. American Council on Science and Health

Bellamy J. 2018 Sep 13. Integrative Medicine finally admits it’s attracting bad apples. Science-Based Medicine

Gorski D. 2018 Sep 14. “Practice drift”: a feature, not a bug, in “integrative medicine." Respectful Insolence

Li B, Forbes TL, Byrne J. 2018. Integrative medicine or infiltrative pseudoscience? Surgeon. 16(5):271-7 [abstract]

Ernst E. 2018 Nov 17. Integrative Medicine: here is my slightly altered and much improved version. Edzard Ernst

Gorski D. 2019 Feb 22. Thomas Jefferson University goes full quack with a department of “integrative medicine.” Respectful Insolence

Ernst E. 2019 Jun 22. Integrative medicine for the US military. A letter from Wayne Jonas. Edzard Ernst

Gorski D. 2019 Oct 2. NIH HEAL Initiative: $1 billion to study “integrative” nonpharmacologic treatments for pain. Respectful Insolence

Marcus DM. 2020. Alternative therapies in academic medical centers compromise evidence-based patient care. J Clin Invest. 130(4):1549-51

Ernst E. 2021 Jan 9. A new definition of "INTEGRATED MEDICINE." Edzard Ernst

Novella S. 2021 Jun 9. Integrative neurology - more bait and switch. Science-Based Medicine

Hall H. 2021 Jul 20. American Academy of Family Physicians supports integrative medicine. Science-Based Medicine

Ernst E. 2021 Oct 31. The 13th European Congress for Integrative Medicine. Edzard Ernst

Ernst E. 2022 May 2. What motivates a doctor to work as an integrative medical practitioner? Edzard Ernst

Gorski D. 2022 Nov 21. ASCO endorses “integrative oncology” quackery for cancer pain. Science-Based Medicine

Functional medicine

Sampson W. 2009 Jul 9-22. Series on functional medicine. Science-Based Medicine. Part 1   Part 2  Part 3  Part 4

Gorski D. 2016 Mar 2. Quackademic medicine: “Wildly successful” at the Cleveland Clinic? Respectful Insolence

Gorski D. 2016 Apr 11. Functional medicine: The ultimate misnomer in the world of integrative medicine. Science-Based Medicine

Gorski D. 2016 Oct 14. Medscape enables functional medicine quackery. Respectful Insolence

Gorski D. 2016 Nov 28. "Functional medicine" in practice. Science-Based Medicine

Gorski D. 2017 Mar 1. “Disruptive” functional medicine at the Cleveland Clinic: Disrupting medicine by mixing quackery with it. Respectful Insolence

Bellamy J. 2017 Oct 26. AAFP: Functional Medicine lacks supporting evidence; includes “harmful” and “dangerous” treatments. Science-Based Medicine

Gorski D. 2018 Jul 24. Stealth advertising for Dr. Mark Hyman and the Cleveland Clinic Center for Functional Medicine. Respectful Insolence

Gorski D. 2018 Sep 5. Dr. Robin Berzin, functional medicine concierge practices, and the marketing of medical pseudoscience. Respectful Insolence

Bellamy J. 2018 Sep 27. AAFP should publish research behind finding that functional medicine lacks evidence, contains harmful and dangerous practices. Science-Based Medicine

Bellamy J. 2018 Nov 8. Goop and Dr. Mark Hyman join forces for some functional medicine heavy metal fear mongering. Science-Based Medicine

Gorski D. 2018 Dec 17. Functional medicine: Reams of useless tests in one hand, a huge invoice in the other. Science-Based Medicine

Gorski D. 2019 Oct 28. The Cleveland Clinic publishes a study claiming to show benefits from functional medicine. It doesn’t. Science-Based Medicine

Gorski D. 2021 Aug 18. Quoth an “integrative” functional medicine doc: “I’m not a quack, I’m an early adopter.” Respectful Insolence

Medical schools and healthcare systems (see also Integrative medicine and Functional medicine)

Marcus DM. 2001. How should alternative medicine be taught to medical students and physicians? Acad Med. 76(3):224-9

Gorski D. 2016 Jun 28. Quackery expands in the Dana Farber Cancer Institute and Children's Hospital of Philadelphia. Respectful Insolence

Bellamy J. 2016 Jul 28. CARA: Integrating even more pseudoscience into veterans' healthcare. Science-Based Medicine

Gorski D. 2016 Aug 26.  The Cleveland Clinic: Promoting dubious diet advice on Twitter and beyond. Respectful Insolence

Hall H. 2016 Sep 6. Alternative medicine is infiltrating veterinary continuing education. Science-Based Medicine

Novella S. 2017 Jan 18. Cleveland Clinic fully embraces pseudoscience. Science-Based Medicine

Gorski D. 2017 Jan 18. The Cleveland Clinic doubles down on its support for quackademic medicine disguised as “wellness.” Respectful Insolence

Gorski D. 2017 Jan 27. Quackery at the VA: Our veterans deserve real medicine, not fake medicine. Respectful Insolence

Ross C, Blau M, Sheridan K. 2017 Mar 7. Medicine with a side of mysticism: Top hospitals promote unproven therapies. STAT

Novella S. 2017 Mar 8. Why do prestigious hospitals sell snake oil? Science-Based Medicine

Gorski D. 2017 Mar 8. Hallelujah! The mainstream press finally notices quackademic medicine! Respectful Insolence

Gorski D. 2017 Mar 20. Is the ACCME cracking down on quackery in continuing medical education (CME) offerings? Richard Jaffe thinks so. Science-Based Medicine

Patel SJ, Kemper KJ, Kitzmiller JP. 2017. Physician perspectives on education, training, and implementation of complementary and alternative medicine. Adv Med Educ Pract. 8:499-503

Ernst E. 2017 Sep 20. A $ 200 million donation to medical research is a good thing… or isn’t it? Edzard Ernst

Bellamy J. 2017 Dec 7. Damn the evidence and regulations: VA goes full speed ahead with medical pseudoscience. Science-Based Medicine

National Center for Complementary and Integrative Health. 2018. Credentialing, licensing, and education

Gorski D. 2018 Feb 12. Quackademic medicine and the delusion of being "science-based." Science-Based Medicine

Gorski D. 2018 Aug 27. Confronting homeopathy, naturopathy, homeopathy, and other quackademic medicine at my alma mater. Science-Based Medicine

Gorski D. 2018 Sep 4. What the Department of Family Medicine at the University of Michigan teaches about acupuncture. Respectful Insolence

Bellamy J. 2020 Feb 27. Quackademic medicine update: UC Irvine reneges on promise of scientific rigor. Science-Based Medicine

Gorski D. 2020 Feb 28. UC-Irvine update: Quackademic medicine continues its takeover. Respectful Insolence

Ernst E. 2022 Jun 14. Quackademia at its most rampant: the "Certificate in Holistic Health and Healing Arts" (HHHA) at the University of New Mexico. Edzard Ernst

Journals and media

Barrett S. 2017. Nonrecommended books. Quackwatch

Barrett S. 2019. Nonrecommended periodicals. Quackwatch

Salzberg S. 2017 Jan 3. Fake medical journals are spreading, and they are filled with bad science. Forbes

Gorski D. 2017 Feb 27. Google delists Mike Adams’ Natural News website. Was it because of fake news? Science-Based Medicine

Gorski D. 2017 May 3. The New York Times publishes fake news false hope in the form of a credulous account of dubious alternative medicine testimonials. Respectful Insolence

Novella S. 2017 May 3. The New York Times: promoting false hope as journalism.  Science-Based Medicine

Gorski D. 2017 May 22. Quackery infiltrates The BMJ. Science-Based Medicine

Gorski D. 2018 Jan 9. Oprah Winfrey for President? Does anyone remember all the pseudoscience and quackery she’s promoted? Respectful Insolence

Rosenbloom C. 2018 Feb 6. These skeptics are using science to fight a wave of bad nutrition advice on the internet. Washington Post

Pruden JG. 2018 Dec 31. Has Tim Caulfield become the Canadian nemesis of pseudoscience? Globe and Mail

Hall H. 2019. Fake news about health products. Skeptical Inquirer. 43(2):32-4

Benson V. 2019. The remedies of National Geographic. Skeptical Inquirer. 43(5):30-6

Hall H. 2019. National Geographic books is a "natural disaster." Skeptical Inquirer. 43(5):37-8

Caulfield T., Marcon AR, Murdoch B, Brown JM, Perrault ST et al. 2019. Health misinformation and the power of narrative messaging in the public sphere. Can J Bioethics. 2(2):52-60

Murdoch B, Marcon AR, Downie D, Caulfield T. 2019. Media portrayal of illness-related medical crowdfunding: A content analysis of newspaper articles in the United States and Canada. PLoS One. 14(4):e0215805

Novella S. 2019 Apr 24. JAMA on medical misinformation. Science-Based Medicine

Mole B. 2019 Jun 10. Facebook bans health and conspiracy site Natural News [Updated]. Ars Technica

Gorski D. 2019 Jun 13. Mike Adams banned from Facebook: Griftus interruptus. Respectful Insolence

Gorski D. 2019 Jun 26. Has Google finally adjusted its algorithm to deprioritize quack content? Dr. Mercola thinks so. Respectful Insolence

Gorski D. 2019 Jul 3. Facebook joins Google in deprioritizing medical misinformation: are social media companies finally “getting it”? Respectful Insolence

Gorski D. 2019 Jul 8. Facebook, Google, and social media vs. medical misinformation: an update. Science-Based Medicine

Gorski D. 2019 Oct 14. Woo versus Wikipedia. Science-Based Medicine

Barrett S. 2020. Web site evaluation index. Quackwatch

Hall H. 2020 Aug 25. “(Un)Well:” Netflix’s documentary series is poor journalism that neglects science. Science-Based Medicine

MacMillan N. 2020 Nov 26. A tough pill to cover. The Signal ["What journalists need to know to report on alternative medicine"]

Ernst E. 2020 Dec 17. Not sure about a news item? … That’s what I suggest you could do. Edzard Ernst

Novella S. 2022 Jan 19. The misinformation dilemma. Science-Based Medicine

Ernst E. 2022 Apr 26. So-called alternative medicine (SCAM) in top mainstream journals from 5 different countries. Edzard Ernst

Ernst E. 2023 Mar 23. The disturbing reason why I no longer accept invitations by 3rd class SCAM journals to act as a peer-reviewer. Edzard Ernst

Gorski D. 2023 May 15. “Subscription science”: Physician-influencers, social media, and conflicts of interest. Science-Based Medicine [see next item]

Mazer BL, Rose MR. 2023. Subscription science: how crowdfunding has become a conflict of interest. BMJ. 381:1063

Organizations

National Council Against Health Fraud. Quackwatch

Crislip M. 2014 Jan 6. Announcing the Society for Science-Based Medicine. Science-Based Medicine

Fidalgo P. 2020 Feb 26. QUACKWATCH Joins the Center for Inquiry. Center for Inquiry Medicine

Gorski D. 2020 Aug 17. Announcement: The Society for Science-Based Medicine is becoming part of the Center for Inquiry. Science-Based Medicine

Harriet Hall. SkepDoc [Dr. Hall died in 2023 but her site remains active.]

Barrett S. 2022. Questionable organizations: an overview. Quackwatch

Legal issues

Barrett S. 2001, Strengths and weaknesses of our laws. Quackwatch

Barrett S. 2001. Pro-quackery legislation. Quackwatch

Cohen MH, Eisenberg DM. 2002. Potential physician malpractice liability associated with complementary and integrative medical therapies. Ann Intern Med. 136(8):596-603 [abstract]

Cohen MH, Kemper KJ. 2005. Complementary therapies in pediatrics: a legal perspective. Pediatrics. 115(3):774-80 [abstract]

Institute for Science in Medicine. 2011. State licensing and regulation of "CAM" practitioners [pdf file]

Bellamy J. 2013 Jun 27. Six reasons CAM practitioners should not be licensed. Science-Based Medicine

Bellamy J. 2017 Oct 12. Repealing legislative alchemy. Science-Based Medicine

Novella S. 2019 Jan 2. Regulating fringe practitioners. Science-Based Medicine

Bellamy J. 2021 Apr 8. "Quack Protection Acts" proposed in state legislatures. Science-Based Medicine

Bellamy J. 2021 May 20. Supreme Court rules that FTC cannot seek restitution on behalf of consumers. Science-Based Medicine

Bellamy J. 2021 Dec 2. Quack Protection Acts advance in state legislatures. Science-Based Medicine

Sánchez L. 2023 May 22. Doctors who spread medical misinformation should lose their licenses. Why don’t they? Current Affairs

Ethical issues

Adams KE, Cohen MH, Eisenberg D, Jonsen AR. 2002. Ethical considerations of complementary and alternative medical therapies in conventional medical settings. Ann Intern Med. 137(8):660-4 [abstract]

Miller FG, Emanuel EJ, Rosenstein DL, Straus SE. 2004. Ethical issues concerning research in complementary and alternative medicine. JAMA. 291(5):599-604 [abstract]

Tilburt JC, Miller FG. 2007. Responding to medical pluralism in practice: a principled ethical approach. J Am Board Fam Med. 20(5):489-94

Ernst E. 2016 Jul 18. Informed consent in alternative medicine? Edzard Ernst

Shahvisi A. 2016. No understanding, no consent: the case against alternative medicine. Bioethics. 30(2):69-76 [abstract]

Macdonald C, Gavura S. 2016. Alternative medicine and the ethics of commerce. Bioethics. 30(2):77-84 [abstract]

Gavura S. 2016 Feb 11. Is it ethical to sell complementary and alternative medicine? Science-Based Medicine

Hall H. 2018 Mar 20. The ethics of CAM: more harm than good? Science-Based Medicine

Ernst E. 2020 Dec 23.A scale of misdemeanors by SCAM [so-called alternative medicine] practitioners towards patients and the public. Edzard Ernst

Ernst E. 2022 Nov 11. Community pharmacists must be reminded of their ethical duty when advising patients about SCAM. Edzard Ernst

Health fraud and quackery - general

Kurtzweil P. 1999. How to spot health fraud. FDA Consum. 33(6):22-6

FDA. 1989 (updated Barrett S. 1999). Top health frauds. Quackwatch

Jarvis WT, Barrett S. 2005. How quackery sells. Quackwatch

Barrett S. 2009. Quackery: how should it be defined? Quackwatch

Barrett S. 2011. "Detoxification" schemes and scams. Quackwatch

Colquhoun D. 2013 Jun 1. If a medical cure looks too good to be true, it probably is. Guardian

Young JH 2016. A historian's view of quackery in 1974. Quackwatch

Ernst E. 2016 Jul 4-9. Tricks of the quackery trade. Edzard Ernst. Part 1 Part 2 Part 3 Part 4 Part 5

Hall H. 2016 Aug 16. Quackery: the 20 Million Dollar Duck. Science-Based Medicine [review of book by Tony Robertson]

Belluz J. 2016 Aug 25 (updated Sep 6). Amazon is a giant purveyor of medical quackery. Vox

Jones C. 2017 Jun 2. Quackery for kids. Science-Based Medicine

Ernst E. 2017 Jun 10. How to protect yourself from bogus claims about so-called alternative medicine. Edzard Ernst

Wilson P. 2017 Jun 28. "What used to be fraud is now alternative medicine." MedpageToday

Gorski D. 2018 Feb 19. True believers, entrepreneurs, and scammers in alternative medicine. Science-Based Medicine

Matthews H. 2018 Dec 26 (updated 2020 Oct 7). Quackwatch™ compiles trustworthy information to debunk health-related frauds impacting couples everywhere. DatingNews.com

Mhatre A. 2020 Apr 26. Tales from the annals of medical quackery. CBS News

Barrett S. 2021. FDA orders 25 companies to stop issuing misleading “FDA registration certificates.” Quackwatch

Federal Trade Commission. 2022. Common health scams

Barrett S. 2022. Promoters of questionable methods and ideas. Quackwatch

Jarvis WT. 2022. The semantics of quackery. Quackwatch

Food and Drug Administration. 2022. Health fraud scams

Public health issues - vaccination

Thompson WW, Price C, Goodson B, Shay DK, Benson P et al. 2007. Early thimerosal exposure and neuropsychological outcomes at 7 to 10 years. N Engl J Med. 357(13):1281-92

Baird G, Pickles A, Simonoff E, Charman T, Sullivan P et al. 2008. Measles vaccination and antibody response in autism spectrum disorders. Arch Dis Child. 93(10):832-7 [abstract]

Parikh RK. 2008 Mar 13. What the Poling autism case means. Salon ["The widely publicized court victory for the family who claimed vaccines caused autism in their daughter does not prove a link."]

Tozzi AE, Bisiacchi P, Tarantino V, De Mei B, D'Elia L et al. 2009. Neuropsychological performance 10 years after immunization in infancy with thimerosal-containing vaccines. Pediatrics. 123(2):475-82 [abstract]

Price CS, Thompson WW, Goodson B, Weintraub ES, Croen LA et al. 2010. Prenatal and infant exposure to thimerosal from vaccines and immunoglobulins and risk of autism. Pediatrics. 126(4):656-64 [abstract]

Goldschmidt D. 2014 Aug 28. Journal questions validity of autism and vaccine study. CNN

Jain A, Marshall J, Buikema A, Bancroft T, Kelly JP, Newschaffer CJ. 2015. Autism occurrence by MMR vaccine status among US children with older siblings with and without autism. JAMA. 313(15):1534-40

Wardle J, Frawley J, Steel A, Sullivan E. 2016. Complementary medicine and childhood immunisation: A critical review. Vaccine. 34(38):4484-4500 [abstract]

Ernst E. 2017 Mar 3. Integrative medicine physicians tend to harbour anti-vaccination views. Edzard Ernst

Bryden GM, Browne M, Rockloff M, Unsworth C. 2018. Anti-vaccination and pro-CAM attitudes both reflect magical beliefs about health. Vaccine. 36(9):1227-34 [abstract and introduction]

Gorski D. 2017 Nov 29. Christopher Exley: Using bad science to demonize aluminum adjuvants in vaccines. Respectful Insolence

Gorski D. 2018 Mar 7. Too many too soon? No! Science-Based Medicine [see next two items]

Glanz JM, Newcomer SR, Daley MF, DeStefano F, Groom HC et al. 2018. Association between estimated cumulative vaccine antigen exposure through the first 23 months of life and non-vaccine-targeted infections from 24 through 47 months of age. JAMA. 319(9):906-13

O'Leary ST, Maldonado YA. 2018. Safety of multiple antigen exposure in the childhood immunization schedule. JAMA. 319(9):870-1 [1st paragraph]

Browne M. 2018. Epistemic divides and ontological confusions: The psychology of vaccine scepticism. Hum Vaccin Immunother. 14(10):2540-2

Gorski D. 2018 Jul 31.The Dunning-Kruger effect, antivaxers, and the arrogance of ignorance. Respectful Insolence [see next item]

Motta M, Callaghan T, Sylvester S. 2018. Knowing less but presuming more: Dunning-Kruger effects and the endorsement of anti-vaccine policy attitudes. Soc Sci Med. 211:274-81 [abstract and introduction]

Gorski D. 2018 Aug 15. Maternal Tdap vaccination during pregnancy is not associated with autism in the child. Respectful Insolence

Novella S. 2018 Aug 22. Vaccines still don't cause autism. Science-Based Medicine

Gorski D. 2018 Aug 28. One more time: HPV vaccination is not associated with primary ovarian insufficiency. Respectful Insolence

Gorski D. 2018 Oct 25. The Republican Party has become the antivaccine party. Respectful Insolence

Hall H. 2019. Diving into the VAERS dumpster: fake news about vaccine injuries. Skeptical Inquirer. 42(6):28-31

Gorski D. 2019 Mar 6. MMR vaccination is not associated with autism, take ∞. Respectful Insolence [see next item]

Hviid A, Hansen JV, Frisch M, Melbye M. 2019. Measles, mumps, rubella vaccination and autism: a nationwide cohort study. Ann Intern Med. 170(8):513-20

Gorski D. 2019 Feb 13. The myth of vaccine shedding. Science-Based Medicine

Gorski D. 2019 Mar 11. Amazon, Facebook, and other streaming and social media platforms are finally cracking down on antivaccine misinformation. Respectful Insolence

Gorski D. 2019 Apr 15. Measles outbreaks and the antivaccine movement. Science-Based Medicine

Gorski D. 2019 May 8. RFK Jr.: So antivaccine that even his family calls him out on it. Respectful Insolence

Gorski D. 2019 Jul 19. Vaccine holocaust: The wildest antivaccine conspiracy theory ever. It even has aliens! Respectful Insolence

Gorski D. 2019 Jul 22. A new study reinforces the conclusion that autism is primarily genetic. Science-Based Medicine

Gorski D. 2019 Aug 5. Is today’s generation of children “the sickest generation”? Science-Based Medicine

Gorski D. 2019 Aug 19. The Vaccine Guide: cherry picked studies and deceptive highlighting in the service of antivaccine pseudoscience. Science-Based Medicine

UNICEF 2020. Vaccine Misinformation Management Field Guide

Novella S. 2020 Jan 8. The harm of antivaccine misinformation. Science-Based Medicine

Gorski D. 2020 Jan 15. No, WHO scientists did not “question the safety of vaccines” at the Global Vaccine Safety Summit. Respectful Insolence

Gorski D. 2020 Feb 7. AAPS sues for its “right” to promote antivaccine misinformation.  Respectful Insolence

Gorski D. 2020 Feb 13. An antivaccine “Circle of Mamas” has “questions” about vaccines. Orac has answers.  Respectful Insolence

Gorski D. 2020 Mar 5. Children’s Health Defense: ten lies about vaccines. Respectful Insolence

Novella S. 2020 Apr 15. The psychology of vaccine denial. Science-Based Medicine

Novella S. 2020 May 6. MMR is safe and effective. Science-Based Medicine

Gorski D. 2020 Jun 19. Antivaxxers Amy Becker and Mark Blaxill deceptively use COVID-19 death statistics to claim that vaccines cause SIDS. Respectful Insolence

Gorski D. 2020 Jun 22. Antivaccine leader Del Bigtree on COVID-19: “Let’s catch this cold!” Why antivaxxers and coronavirus conspiracy theorists are often one in the same. Science-Based Medicine

Hall H. 2020 Sep 8. New book: Anti-vaxxers: How to Challenge a Misinformed Movement. Science-Based Medicine

Gorski D. 2020 Sep 28. The confluence of antivaccine beliefs and conspiracy theories in COVID-19 denial. Science-Based Medicine

Steinmetz PN. 2020. The scientific frauds underlying the false MMR vaccine–autism link. Skeptical Inquirer. 44(6):30-4

Gorski D. 2021 Jan 13. RFK Jr. doesn’t like being called antivaccine and antimask. Respectful Insolence

Barrett S. 2021 Jan 15. Social media urged to block antivax “superspreaders.” Quackwatch

Bellamy J. 2021 Feb 25. Bills eliminating school immunizations and other anti-vaccination measures confront state legislatures. Science-Based Medicine

Ernst E. 2021 Sep 14. Many naturopaths, homeopaths, and chiropractors are a risk to public health. Edzard Ernst

Ernst E. 2021 Nov 18. The American Medical Association take a stand against chiropractors, naturopaths, or homeopaths granting medical exemptions to vaccines. Edzard Ernst

Ernst E. 2022 Mar 12. Preference of so-called alternative medicine predicts negative attitudes to vaccination. Edzard Ernst

Gorski D. 2022 Apr 18. Why is anyone surprised that there are so many antivax physicians? Science-Based Medicine [see next item]

Callaghan T, Washburn D, Goidel K, Nuzhath T, Spiegelman A et al. 2022. Imperfect messengers? An analysis of vaccine confidence among primary care physicians. Vaccine. 40(18):2588-2603

Gorski D. 2022 Apr 22. Eliminating school vaccine mandates is the antivax endgame. Respectful Insolence

Gorski D. 2022 May 27. Radical COVID-19 antivax sentiment is metastasizing to childhood vaccines. Respectful Insolence

Gorski D. 2022 Aug 13. Antivax and transphobia: two crappy tastes that taste crappy together. Respectful Insolence

Gorski D. 2022 Aug 15. Antivaxxers rejoice at the “silver lining” from the pandemic, spillover of distrust of COVID-19 vaccines to all vaccines. Science-Based Medicine

Mole B. 2022 Aug 17. Anti-vaccine activists giddily celebrate as poliovirus spreads in NY.  Ars Technica

Jones C. 2022 Sep 30. Impressive new data on the benefit of childhood vaccines. Science-Based Medicine

Gorski D. 2023 Feb 13. Vaccines and infant mortality rates: A false relationship promoted by the antivaxxers…again, 12 years later. Science-Based Medicine

Gorski D. 2023 Mar 27. Autism prevalence increases to 1 in 38, and antivaxxers blame vaccines without using the word “vaccine.” Science-Based Medicine

Gorski D. 2023 May 19. “CDC whistleblower” conspiracy theory, resurrected by “new school” antivaxxers. Respectful Insolence

Gorski D. 2023 Jun 28. Return of the revenge of “no saline placebo RCTs” for childhood vaccines. Respectful Insolence

Public health issues - fluoridation

Dodes JE, Easley MW. 2012. The anti-fluoridation threat to public health. Institute for Science in Medicine [pdf file]

Barrett S. 2014 Jul 19. Fluoridation is highly beneficial - don't let poisonmongers scare you. OpEdNews

Broadbent JM, Thomson WM, Ramrakha S, Moffitt TE, Zeng J et al. 2015. Community water fluoridation and intelligence: prospective study in New Zealand. Am J Public Health. 105(1):72-6

Novella S. 2019 Aug 21. Maternal fluoride and IQ. Science-Based Medicine

Hall H. 2019. Water fluoridation: public health, not poison. Skeptic. 24(4):4-5

Hall H. 2021. Does public water fluoridation make children less intelligent? Skeptical Inquirer. 45(3):18-20

MacBeth B. 2021 Jun 19. Bad documentary review: The Great Culling. Science-Based Medicine

Science and pseudoscience, critical thinking, scientific methods

Science-Based Medicine ["Exploring issues & controversies in science & medicine"]

edzardernst.com/ [blog from one of the leading researchers in alternative medicine]

Respectful Insolence ["The miscellaneous ramblings of a surgeon/scientist on medicine, quackery, science, and pseudoscience (and anything else that interests him)."]

Lett J. 1990. A field guide to critical thinking. Skeptical Inquirer. 14(2):153-60

Smith GL. 1997. Common questions about science and "alternative" health methods.  Quackwatch

Stenger VJ. 1998. "Postmodern" attacks on science and reality. Quackwatch

Coker R. 2001. Distinguishing science and pseudoscience. Quackwatch

Alcock J. 2001. "Alternative medicine" and the psychology of belief. Quackwatch

Sterne JA, Egger M, Smith GD. 2001. Systematic reviews in health care: Investigating and dealing with publication and other biases in meta-analysis. BMJ. 323(7304):101-5

Schwarcz J, Barrett S. 2001. Some notes on the nature of science. Quackwatch

Beyerstein B. 2003. Why bogus therapies often seem to work. Quackwatch

Ioannadis JPA. 2005. Contradicted and initially stronger effects in highly cited clinical research. JAMA. 294(2):218-28 [found that in about one-third of highly cited studies showing effectiveness of an intervention, subsequent studies found no effect or weaker effects]

Sampson W. 2007. Whatever happened to plausibility as the basis for clinical research and practice after EBM and CAM rushed in? MedGenMed. 9(1):19

Ernst E. 2009. Complementary/alternative medicine: engulfed by postmodernism, anti-science and regressive thinking. Br J Gen Pract. 59(561):298-301

Power M, Hopayian K. 2011. Exposing the evidence gap for complementary and alternative medicine to be integrated into science-based medicine. J R Soc Med. 104(4):155-61

Hammerstrøm KT, Bjørndal A. 2011. If there are no randomised controlled trials, do we always need more research? Cochrane Database Syst Rev. 14;(8):ED000024

Ernst E. 2012. Errors of alternative medicine: lessons for general practice. Eur J Gen Pract. 18(1):63-6

Sense About Science. 2013. I don’t know what to believe...: making sense of science stories [pdf file, aimed at the lay person, explaining the peer review process]

McGlothlin AE, Lewis RJ. 2014. Minimal clinically important difference: defining what really matters to patients. JAMA. 312(13):1342-3 [abstract]

Gorski DH, Novella SP. 2014. Clinical trials of integrative medicine: testing whether magic works? Trends Mol Med. 20(9):473-6. See also response: Rutten LA, Mathie RT, Manchanda RK. 2014. Making sense of prior probabilities in research. Trends Mol Med. 20(11):599-600 [abstract] and rebuttal: Gorski DH, Novella SP. 2014. Considering prior plausibility in clinical trials does not mean ignoring scientific evidence. Trends Mol Med. 20(11):600-1 [abstract]

Pandolfi M, Carreras G. 2014. The faulty statistics of complementary alternative medicine (CAM). Eur J Intern Med. 25(7):607-9 [abstract]

Nuzzo R. 2014. Scientific method: statistical errors. Nature. 506(7487):150-2

Novella S. 2015. It's time for science-based medicine. Skeptical Inquirer. 39(3):22-4

Hall H. 2015. Science based medicine. JamesRandiFoundation [set of videos]

Ernst E. 2016 Jan 7. Five ways to mislead people with seemingly rigorous trials. Edzard Ernst

Barrett S. 2018. More ploys that can fool you. Quackwatch

Hall H. 2018 Feb 13. Answering our critics - again! Science-Based Medicine

Ernst E. 2018 Mar 16. Beware of (poor-quality, redundant, nonsensical, biased) systematic reviews. Edzard Ernst [see also next item]

Ioannidis JP. 2016. The mass production of redundant, misleading, and conflicted systematic reviews and meta-analyses. Milbank Q. 94(3):485-514 [see also previous item]

Ernst E. 2018 Apr 6. "Pilot studies" of alternative medicine: incompetent, unethical, misleading and harmful. Edzard Ernst

Novella S. 2018 Jun 4. Indigenous ways of knowing. Neurologica

Gorski D. 2018 Jun 11. Science-based medicine versus other ways of knowing. Science-Based Medicine

Pandolfi M, Carreras G. 2018. Why current statistics of complementary alternative medicine clinical trials is invalid. J Clin Med. 7(6):138

Ernst E. 2018 Jul 17. Medical research is often unreliable. But research into alternative medicine is much worse, and here is why. Edzard Ernst

Ernst E. 2019 Feb 18. What can consumers do when they are confronted with confusing or contradictory evidence? Edzard Ernst

Ernst E. 2019 Aug 20. A framework for critical thinking. Edzard Ernst

Ernst E. 2019 Sep 25. The de-randomised clinical trial (dRCT): how we might be fooled by seemingly rigorous research. Edzard Ernst

Weinberg D. 2020 Apr 30. The p-hackers toolkit. Science-Based Medicine

Ernst E. 2020 Sep 7. Reasons why ineffective treatments can appear to be effective. Edzard Ernst

Ernst E. 2020 Oct 19. Manifesto against pseudosciences in health. Edzard Ernst

Ernst E. 2020 Dec 5. How to mislead the public with seemingly solid research. Edzard Ernst

Gorski D. 2021 Jan 25. All science denial is a form of conspiracy theory. Science-Based Medicine

Novella S. 2022 Sep 7. But is it real? Science Based Medicine

Ernst E. 2023. Applying science to SCAM: a brief summary of the past thirty years. Skeptical Inquirer. 47(1):11-2

Gorski D. 2023 Mar 13. The Cochrane mask fiasco: How the evidence-based medicine paradigm can produce misleading results. Science-Based Medicine

Novella S. 2023 May 31. Why scientific plausibility matters. Science Based Medicine

Complementary and alternative methods for specific areas of medicine

Note: see also references listed in the text. Some areas, such as cancer and arthritis, are covered in other articles.

National Center for Complementary and Integrative Health 2018. Anxiety at a glance

National Center for Complementary and Integrative Health 2022. Asthma and complementary health approaches: what you need to know

National Center for Complementary and Integrative Health 2019. Attention-deficit hyperactivity disorder at a glance

National Center for Complementary and Integrative Health 2017. Autism

National Center for Complementary and Integrative Health 2020. Cardiovascular disease

Rapaport 2019 May 1. Alternative medicine practitioners may market bogus celiac tests, treatments. Reuters

Ernst E. 2023 Mar 31. ME/CFS [myalgic encephalomyelitis/chronic fatigue syndrome]: Yes, the ‘Lightning Process’ is nonsense, but is there any other so-called alternative medicine worth trying? Edzard Ernst

Ernst E. 2017 Dec 16. Alternative treatments for the common cold: good business, bad evidence. Edzard Ernst

Ernst E. 2018 Apr 18. Alternative treatments for diabetes: I strongly advise caution. Edzard Ernst

National Center for Complementary and Integrative Health. 2016. Fibromyalgia: in depth

Ernst E. 2017 May 17. More BS from the BMJ. Edzard Ernst [headache]

National Center for Complementary and Integrative Health 2021. Headaches: what you need to know

Ernst E. 2022 12 Dec. So-called alternative medicine (SCAM) for heart failure. Edzard Ernst

Gavura S. 2023 Feb 2. CAM for the management of heart failure. Science-Based Medicine

National Center for Complementary and Integrative Health 2018. Hypertension (high blood pressure)

Ernst E. 2020 Aug 24. Treatment of hypertension with so-called alternative medicine (SCAM): a summary of systematic reviews. Edzard Ernst

National Center for Complementary and Integrative Health 2023. Irritable bowel syndrome: what you need to know

National Center for Complementary and Integrative Health 2017. Menopausal symptoms: in depth

National Center for Complementary and Integrative Health 2019. Multiple sclerosis

Ernst E. 2016 Mar 28. NICE [National Institute for Health and Care Excellence, UK] no longer recommends acupuncture, chiropractic or osteopathy for low back pain. Edzard Ernst

Ernst E. 2016 Sep 5. Unacceptable pseudo-science from the NIH. Edzard Ernst [chronic pain]

Gorski D. 2016 Sep 5. “Non-pharmacological treatments for pain” ≄ CAM, no matter how much NCCIH wishes it so. Science-Based Medicine

Gorski D. 2016 Nov 4. JAMA: a willing accomplice to co-opting “nonpharmacologic” treatments for pain as being “alternative” or “complementary.” Respectful Insolence

Gorski D. 2017 Feb 14. The American College of Physicians integrates quackery with medicine in its recommendations for managing back pain. Respectful Insolence

Ernst E. 2017 May 9. Alternative medicine for chronic pain: ‘State of the Art’ review in the BMJ. Edzard Ernst

Ernst E. 2017 May 15. Harms of nonpharmacologic therapies (the new ACP guideline). Edzard Ernst

Gorski D. 2017 May 15. Is the FDA embracing quackery? A draft proposal recommends that doctors learn about acupuncture and chiropractic for pain management. Science-Based Medicine

Hall H. 2017 Jun 27. Consumer reports misses the boat on back pain. Science-Based Medicine

Ernst E. 2018 Mar 24. Low back pain: alternative practitioners feel encouraged by the recent Lancet-articles – wrongly so, I hasten to add. Edzard Ernst

Bellamy J. 2018 Apr 12. Hypothesized benefit from integrative treatments for veterans’ chronic pain fails to materialize. Science-Based Medicine

Bellamy J. 2019 Sep 12. New Florida law forces physicians to endorse pseudoscience. Science-Based Medicine [pain]

Ernst E. 2019 Dec 12. Does SCAM [so-called alternative medicine] reduce opioid use for chronic pain? Edzard Ernst

National Center for Complementary and Integrative Health 2020. Low-back pain and complementary approaches: what you need to know

Gorski D. 2020 Feb 11. Can CAM help alleviate musculoskeletal symptoms in breast cancer patients from aromatase inhibitors like letrozole? Respectful Insolence

Ernst E. 2020 Oct 8.So-called alternative medicine for post-caesarean pain? A Cochrane review. Edzard Ernst

National Center for Complementary and Integrative Health 2023. Chronic pain: what you need to know

Ernst E. 2018 Aug 21. The use of CAM in palliative care is highly problematic. Edzard Ernst

National Center for Complementary and Integrative Health 2018. Parkinson's disease at a glance

Ernst E. 2018 Sep 10. Alternative therapies for psoriasis? A poor review in a top journal. Edzard Ernst

National Center for Complementary and Integrative Health 2019. Skin conditions

National Center for Complementary and Integrative Health 2015. Sleep disorders: in depth

National Center for Complementary and Integrative Health 2021. Quitting smoking

National Center for Complementary and Integrative Health 2021. Women's health and complementary approaches